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-   -   Already had fusion, need a...... (https://www.neurotalk.org/spinal-disorders-and-back-pain/146055-fusion.html)

Broken at Work 03-05-2011 02:43 AM
Already had fusion, need a......
 
I was injured on the job, originally in 2002 after falling. I went through their physical therapy, pm, on my lower back. I tried telling them that I was having pain in my neck, but the company doctors kept telling me that the muscles in my neck were working hard because of the injury to my lower back. They released me to go back to work on modified duty. That was a joke. Anyhow, in 2004, my family doctor took me out of work as I was blacking out. Come to find out, it was because of disc's in my neck. I filed a workers comp case. Their orthopedic surgeon decided that by doing a fusion in between the damaged disc's, that it would stabilize the others. This was in 2005, it didn't work. I've had to have both of my shoulders done, and even though I've had two neurosurgeons advise me and right up reports stating that I need a triple fusion, the insurance company wouldn't authorize it because their doctor that saw me for all of 15 minutes, said that I didn't need it, that I was faking it. Anyhow, now that I'm on social security disability, I have to pay for my workers comp injury, and I'm in an extreme amount of pain. I need to find somewhere that I can get my surgeries on my neck, and my lower back down for as reasonably inexpensively as I can without risking my health. I live in Southern California. If anyone has any advice or suggestions, I'd sure like to hear them. Thanks :)

Leesa 03-05-2011 05:03 PM
I don't understand ~ Why can't SSdisability & Medicare pay for it??? Why do YOU have to pay for it? It shouldn't matter that it was pre-existing. They should pay for it anyway! Who told you that they wouldn't??

Call your SS office, and find out for sure. I'm almost POSITIVE that SS and medicare will pay for this surgery. Either that, or I'm really ignorant. Since W/C denied it, I don't see why they wouldn't pay for it. Hugs, Lee

Jomar 03-05-2011 07:02 PM
Is your wc claim closed or just denied?

You can appeal, do you have a wc atty??, sounds like you need a good one.

We do have a work comp forum if your claim is still active.
http://neurotalk.psychcentral.com/forum30.html

Broken at Work 03-05-2011 11:10 PM
At a loss....
 
Quote:
Originally Posted by Leesa (Post 750392)
I don't understand ~ Why can't SSdisability & Medicare pay for it??? Why do YOU have to pay for it? It shouldn't matter that it was pre-existing. They should pay for it anyway! Who told you that they wouldn't??

Call your SS office, and find out for sure. I'm almost POSITIVE that SS and medicare will pay for this surgery. Either that, or I'm really ignorant. Since W/C denied it, I don't see why they wouldn't pay for it. Hugs, Lee
My attorney said that medicare will only pay after I pay the first $60,000.00 unless I don't do a compromise and settle, which closes the case. If I don't go that direction and keep future medical open, I will 1.) end up with no monies out of it, and 2.) I'm not sure if I have to continue to fight with the insurance company to try and get the surgery. They've been denying it for the last couple of years or so. That's why I feel as though I'm caught between a rock and a hard place right now, and I've got to make a decision in the next day or so, as I need to let her know before Wed. A hearing is set for that day, and she says that I'd get less if it goes before the judge.

Dubious 03-06-2011 11:14 AM
Quote:
Originally Posted by Broken at Work (Post 750231)
I was injured on the job, originally in 2002 after falling. I went through their physical therapy, pm, on my lower back. I tried telling them that I was having pain in my neck, but the company doctors kept telling me that the muscles in my neck were working hard because of the injury to my lower back. They released me to go back to work on modified duty. That was a joke. Anyhow, in 2004, my family doctor took me out of work as I was blacking out. Come to find out, it was because of disc's in my neck. I filed a workers comp case. Their orthopedic surgeon decided that by doing a fusion in between the damaged disc's, that it would stabilize the others. This was in 2005, it didn't work. I've had to have both of my shoulders done, and even though I've had two neurosurgeons advise me and right up reports stating that I need a triple fusion, the insurance company wouldn't authorize it because their doctor that saw me for all of 15 minutes, said that I didn't need it, that I was faking it. Anyhow, now that I'm on social security disability, I have to pay for my workers comp injury, and I'm in an extreme amount of pain. I need to find somewhere that I can get my surgeries on my neck, and my lower back down for as reasonably inexpensively as I can without risking my health. I live in Southern California. If anyone has any advice or suggestions, I'd sure like to hear them. Thanks :)
Is your case still open, have you had panel QME (Qualified Medical Examination) from the state before you were represented?

It is a very bad omen when you are complaining about multiple regions of pain initially after the accident but your doc apparently only diagnoses and treats a lower back injury. If your neck or other regions were injured in the fall but not reported by the initial medical physician and then you push to add them later, the ins. carrier will very likely view that as embellishment or fraudulent. If your neck was not ACCEPTED by the ins. carrier, it seems that you should be able to see a doctor independant of your WC claim.

It starts to get complicated on who should pay. And treatment is regionally specific (the area of your body that was hurt) to the ACCEPTED diagnosis. If your case is "open" then you are at the mercy of the ins. co. doc or you are treating on a "green lein" thru a WC attorney. If your case is closed with no future medical, then any other insurance you have is a potential reimburser. If your case is closed WITH future medical, then you are back to bowing to the mercy of the ins. co. doc for the ACCEPTED diagnosis.

Ongoing care while your case is open is subject to ins. review (and ACOEM) but if your case is closed, further care is specifically addressed by the physician who authored your "permanent and stationary" report, the QME report (if done) or some variation thereof thru "compromise and release" or stipulation and award." All of the medical treatment however is subject to scrutiny by the good book from the American College of Occupational and Enviornmental Medicine (ACOEM). Really sucks!

Broken at Work 03-07-2011 04:17 PM
Frustrated
 
Yes, my case is still open, but only for a couple more days or so. I either have to settle, or it will go before a judge on the 9th, which is Wed. My attorney advised me that if it goes before a judge that I will get even less than what the insurance company is offering me, so I don't want that to happen.
I did see a QME, and the percentage of my permanent disability is based upon his report, minus what they percentaged out for my prior neck and shoulder surgeries. It's hard to battle when I saw 2 different neurosurgeons and they said that I needed neck surgery, that the one they did wasn't successful vs seeing their orthopedic surgeon for 15-20 minutes who took X-Rays and said that I don't need it.

As far as my neck injury, it was being handled by the secondary workers comp case as an accumulative injury, as well as my shoulders.

So, my dilema is, keeping future medical and basically getting no money except, maybe a couple of thousand after attorney's fee's and paying back the advanced monthly payments. Or taking the compromise and settlement and closing out the case, with no future, I have to take care of my own medical, and I have to pay the first $60,000 before medicare will pay if it has to do with the workers comp injuries to my neck, shoulders or lower back.

That's why I've been asking for suggestions and opinions. I'm at a roadblock here. I'm a single mom, even though my kids are grown, one of my daughters lives with me as well as her 3 little ones, ages 8, 2, and 4months. She works and helps me, and takes care of the house.



Quote:
Originally Posted by Dubious (Post 750562)
Is your case still open, have you had panel QME (Qualified Medical Examination) from the state before you were represented?

It is a very bad omen when you are complaining about multiple regions of pain initially after the accident but your doc apparently only diagnoses and treats a lower back injury. If your neck or other regions were injured in the fall but not reported by the initial medical physician and then you push to add them later, the ins. carrier will very likely view that as embellishment or fraudulent. If your neck was not ACCEPTED by the ins. carrier, it seems that you should be able to see a doctor independant of your WC claim.

It starts to get complicated on who should pay. And treatment is regionally specific (the area of your body that was hurt) to the ACCEPTED diagnosis. If your case is "open" then you are at the mercy of the ins. co. doc or you are treating on a "green lein" thru a WC attorney. If your case is closed with no future medical, then any other insurance you have is a potential reimburser. If your case is closed WITH future medical, then you are back to bowing to the mercy of the ins. co. doc for the ACCEPTED diagnosis.

Ongoing care while your case is open is subject to ins. review (and ACOEM) but if your case is closed, further care is specifically addressed by the physician who authored your "permanent and stationary" report, the QME report (if done) or some variation thereof thru "compromise and release" or stipulation and award." All of the medical treatment however is subject to scrutiny by the good book from the American College of Occupational and Enviornmental Medicine (ACOEM). Really sucks!

Jomar 03-07-2011 04:39 PM
It all comes down to making a list of possible future costs and a list of pros and cons for each decision..then pray and go with what feels best for you.

other ?? to think about
Will you be able to work possibly in the future
will you have some sort of pvt med ins
Other options for future consideration
SSDI? SSI? - we have a forum for these too.

why does atty say you would get less $:confused:
atty not prepared , not a solid case of evidence & paper trail

If not prepared or more info & reports might be needed I think atty can ask for a reschedule /postponement.

Are you set at MMI - max med improvement - stable - more or less?

I have a question about the shoulders - what was done for them and I wonder what other neck sx you are having?
Anything with your arms/hands?

Dubious 03-07-2011 04:40 PM
Quote:
Originally Posted by Broken at Work (Post 750909)
Yes, my case is still open, but only for a couple more days or so. I either have to settle, or it will go before a judge on the 9th, which is Wed. My attorney advised me that if it goes before a judge that I will get even less than what the insurance company is offering me, so I don't want that to happen.
I did see a QME, and the percentage of my permanent disability is based upon his report, minus what they percentaged out for my prior neck and shoulder surgeries. It's hard to battle when I saw 2 different neurosurgeons and they said that I needed neck surgery, that the one they did wasn't successful vs seeing their orthopedic surgeon for 15-20 minutes who took X-Rays and said that I don't need it.

As far as my neck injury, it was being handled by the secondary workers comp case as an accumulative injury, as well as my shoulders.

So, my dilema is, keeping future medical and basically getting no money except, maybe a couple of thousand after attorney's fee's and paying back the advanced monthly payments. Or taking the compromise and settlement and closing out the case, with no future, I have to take care of my own medical, and I have to pay the first $60,000 before medicare will pay if it has to do with the workers comp injuries to my neck, shoulders or lower back.

That's why I've been asking for suggestions and opinions. I'm at a roadblock here. I'm a single mom, even though my kids are grown, one of my daughters lives with me as well as her 3 little ones, ages 8, 2, and 4months. She works and helps me, and takes care of the house.

And that's a good point.....future medical on a stipulation and award is worth tens of thousands if not hundreds of thousands over a life time depending how old you are. Your attorney will get by law, 12%-15% of the monetary award, which would normally be decided by the judge at the hearing. They are not entitled to your future med award, I don't think. A compromise and release is just that! My experience has been a C&R is worth less than a stipulation and award. There must be something extraordinary about your case. Unfortunately, WC is not tort law so the awards are much less.

Broken at Work 03-08-2011 08:08 PM
Quote:
Originally Posted by Dubious (Post 750913)
And that's a good point.....future medical on a stipulation and award is worth tens of thousands if not hundreds of thousands over a life time depending how old you are. Your attorney will get by law, 12%-15% of the monetary award, which would normally be decided by the judge at the hearing. They are not entitled to your future med award, I don't think. A compromise and release is just that! My experience has been a C&R is worth less than a stipulation and award. There must be something extraordinary about your case. Unfortunately, WC is not tort law so the awards are much less.
I'm 54 and I receive SSI & SDI, that's why I'm already receiving medicare. My attorney gets 15% of the monetary award only, nothing else. Cash wise, I get more money in hand if I go with a C&R, but I'm responsible for the first $60,000 in any medical expenses that has to do with my comp injuries, then medicare will pick up after that. The only way around that, would be if I was able to go to work, or if I were able to get other health insurance that would pay for it or if those areas were re-injured some other way in an car accident or something like that.
Pretty risky considering that that could completely paralyze me. Anyhow, if I go with a stipulation and keep future medical, I put maybe a couple of thousand dollars in my pocket, and then put up with whatever of their **** to get my neck surgery done, just as I've been fighting for the last 2 or 3 years now.

I had a message today that the hearing that was set for tomorrow has been taken off calendar, but that there are some releases that my attorney needs me to sign. I think that they are for the C&R. I will find out tomorrow. :confused:


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