Case Denied

[tltaylo]

I recently injured my neck on the job and was treated as a Workmans comp claim buy my employer and My Dr. says I need surgery I am in severe pain and now ESIS has Denied my surgery certified that I need it. My Private insurance Aenta will not cover it because they said It is a Workmans comp case. I don't know how to handle this. I need surgery quick. Any one have any ideas?

[Bummer Knees]

First we need your state as work comp is state specific.

Next, Do you have a work comp attorney?

Denial of medical treatment is a good reason to hire a work comp attorney.

There is a new attorney locator at the bottom of this page.

Good Luck!

[1171]

you can appeal to the comp court but that is not quick.
you might be able to appeal the aetna denial to your state's department of insurance.
check out your consumer insurance rights on your state's web page.
your health insurer also has an appeal process.
you can also pay for it yourself and then request reimbursement later.
if you have a good relationship with your employer they might contact the carrier for you and put some pressure on them to reverse the denial.

[tltaylo]

Bummer Knees Wrote:First we need your state as work comp is state specific.

Next, Do you have a work comp attorney?

Denial of medical treatment is a good reason to hire a work comp attorney.

There is a new attorney locator at the bottom of this page.

Good Luck!

I live in Houston, Tx. and I was left with no choice but to hire a attorney. Thank You

[Lucho]

you need to get an AME doctor (neutral doctor) and or hire an attorney but dont hire any attorney, because there are some attorneys that you wont even meet. Its better to do a good search on your own. And ask the attorney to go to the board and fight your case.
if you live in california i may be able to give you better advice.
send me an email: luis.morales59@yahoo.com

[tltaylo]

1171 Wrote:you can appeal to the comp court but that is not quick.
you might be able to appeal the aenta denial to your state's department of insurance.
check out your consumer insurance rights on your state's web page.
your health insurer also has an appeal process.
you can also pay for it yourself and then request reimbursement later.
if you have a good relationship with your employer they might contact the carrier for you and put some pressure on them to reverse the denial.

I have tried everthing, I have talked to the company they say they can't do anything because of patient confidentiality, I am still working but it is getting harder every day, I have hired a attorney so I am waiting on that. This system is broken

[1171]

HIPAA rules on patient confidentiality do not apply to workers comp claims.

[AQA]

tltaylo. Please forgive me, but I am lost.

Has your claim been denied or is it the surgery that has been denied???? I am confused. That could be due to several reasons.

If it is the surgery. The dr. needs to make the request again. You should get a copy of it. I know that you have been getting copies of all your medical records as well as keeping copies of all correspondence from the IC. Right????

Anyway, once the second request has been made. The IC has (if memory serves me) 3 business days to respond. If it is denied the second time. Then a request for an IRO (Independent Review Organization) needs to be made. The IRO is a panel of DR.s (3) that will review your medical records ( remember, the ones you have been collecting) they will decide wether the surgey is needed. Thier decision is all it takes. If they say yes, then you will have the surgery. If they say no. Then you will send a copy of the denial to your personal health care provider and take it from there. Once your personal health care provider gets a copy of the denial. Then they will cover it.

[Bummer Knees]

Good information AQA!