[CA] L5 back injury--need advice for husband

[bamabess]

Hi, all,

I would appreciate your advice about a specific problem related to my husband's WC claim.

My otherwise healthy husband suffered a left-side herniated disc at L5 about three weeks ago. The pain on the S1 nerve down his left leg was so severe that he was hospitalized for six days; he couldn't get out of the fetal position for the first three days. That hospitalization ate up the $10,000 WC is required to pay for medical treatment. Now he is out of the hospital, but is totally bed bound except for occasional walks to the bathroom or kitchen. He can't sit up for more than about five minutes without being in terrible pain.

The WC claim has been delayed while they investigate whether this was a pre-existing injury, because he had back surgery on L4 back in 1995 for a herniation as well. He's had no back problems between 1995 and 2010.

Here's the problem. The $10,000 is gone, the claim is delayed, and they have required a QME review. They've said this can take up to 15 business days just to provide a list of three doctors, let alone get him in to see someone. The WC company doesn't recognize our private insurance as a provider, so they will not reimburse any visits, medications, etc., that he might need between now and then with his primary care physician. The private insurance has said they can't treat him because it's a WC claim and they won't be paid. How is he supposed to get medical care between now and the time he sees a QME?

This whole situation seems highly unethical to me. Has anyone else been in this situation? Any advice about how to handle it? Thanks in advance.

[fireball]

what state are you from??? each state is different in the workcomp laws and when we know the state it is easier for us to respond.
im from il. and i only know their law
i have never heard of a state setting the medical claims of an individual at 10,000.00. and then you are on your own, that is why we have attorneys

if his workcomp insurance company is not paying the bills alll you need is a written statement from them stating they no longer are paying your medical bills. by law your private insurance or medicare must pick the bill up

obviously, you will have to take them to a workcomp trial you should be awarded past medical (if he can prove this was a work related injury) what your insurance has paid which you will repay with the award--
if you settle between the two of you make sure they put this reimbursement amount is in as the private insurance will want their remibursement

if you do not have an attorny get one as like i said i have never heard of any state saying you only get 10,000.00 of medical care for an injury just does not make sense
either yourself or your attorney needs to obtain a written letter form workcomp stating they are no longer going to pay your medical bills--therefore his medical bills will be taking care of
he should also be getting a weekly ttd if not have the attorney file a motion asap to get it
so they are requesting a qme but not right away this tells me that they know they owe you and want to delay delay delay otherwise they hire these drs. to write false reports and the sooner they can get us in the better in order for the workcomp to have a reason to stop ttd payments. so it sounds as like they know they are liable to him
let us know what state and keep us updated

cheers!!!!!!

[nursedina]

bamabess Wrote:Hi, all,

I would appreciate your advice about a specific problem related to my husband's WC claim.

My otherwise healthy husband suffered a left-side herniated disc at L5 about three weeks ago. The pain on the S1 nerve down his left leg was so severe that he was hospitalized for six days; he couldn't get out of the fetal position for the first three days. That hospitalization ate up the $10,000 WC is required to pay for medical treatment. Now he is out of the hospital, but is totally bed bound except for occasional walks to the bathroom or kitchen. He can't sit up for more than about five minutes without being in terrible pain.

The WC claim has been delayed while they investigate whether this was a pre-existing injury, because he had back surgery on L4 back in 1995 for a herniation as well. He's had no back problems between 1995 and 2010.

Here's the problem. The $10,000 is gone, the claim is delayed, and they have required a QME review. They've said this can take up to 15 business days just to provide a list of three doctors, let alone get him in to see someone. The WC company doesn't recognize our private insurance as a provider, so they will not reimburse any visits, medications, etc., that he might need between now and then with his primary care physician. The private insurance has said they can't treat him because it's a WC claim and they won't be paid. How is he supposed to get medical care between now and the time he sees a QME?

This whole situation seems highly unethical to me. Has anyone else been in this situation? Any advice about how to handle it? Thanks in advance.

Bama - I too have enver heard of a 10,000 cap on workman's comp. And workman;s comp will usually cover a pre-existing condition (as far as I know) as long as the aggravation and injury causing this problem happened at work.

for instance - I pulled my back out on a sunday while I was at home. I called work to tell them I could not com ein on Monday because I hurt my back, they told me to come in anyway cause I was th eonly nurse they had. I came in, at the end of the day I bent over a patient and the disc blew out. WC knows all this and they had to accept the claim because the herniation happened at work.

[bamabess]

Thanks, everyone. My understanding is that the $10,000 isn't a cap... it's the initial amount WC is required to pay in California whether the claim is approved or not. That's the money that has already been used. Now they are deciding whether or not to accept the claim and pay for the rest of his treatment. I hope that clarifies my question... let me know if you need more info.

(Sorry for the confusion about the state... I tried to specify "CA" in the post title, but it looks like it would've been helpful to include it in my post as well.)

[1171]

the Health insurer should pay while the claim is under delay--they can file a lien to get re-imbursed later.
send them a copy of the delay letter from the comp carrier.
the state of california also has an agency to help consumers deal with health insurers. you may wish to contact them to intercede.

[bamabess]

1171 Wrote:the Health insurer should pay while the claim is under delay--they can file a lien to get re-imbursed later.
send them a copy of the delay letter from the comp carrier.
the state of california also has an agency to help consumers deal with health insurers. you may wish to contact them to intercede.

That's how it is working out... they are filing the lien. Thanks for the advice!

[1171]

yup that's the way it worked for years before there was any delay money.