[lefthanded]

I am reading these threads, seeing so much misinformation, sharing of information that is specific to certain claims for certain people in certain states, and hearing fear, confusion and worry . . . I would love to help! However, I can not set myself up as an expert and give legal advice, nor have I worked claims in every state and those I did have probably changed their laws somewhat since then . . .

But there are some very basics that I could offer to help you through the "system."

Is there an interest? What are your most pressing questions or issues? And what is it that you don't understand, find confusing, or find depressing about being on workers compensation?



i will begin by saying Workers Compensation Insurance is a state run program. Your employer, and most of the time you, pay premiums each month (yours comes out in payroll taxes), and those premiums are set according to the degree of hazard and the number and costs of claims your employer experiences on average in your state. They desire to keep these premiums, and their costs, low . . . and this can lead to conflicts over coverage, allowance and sometimes even the handling of your claim. This is why attorneys are sometimes needed. Because workers compensation was instituted over 100 years ago to take the burden off the injured worker, it is supposed to be a no-fault system. If your injury happened on the job -- the language usually includes the words "arising out of" and/or "in the course of" your job duties and activities, it is supposed to be covered. W/C was designed to make sure the worker got proper medical treatment, to replace the lost wages with a benefit that would keep them from economic ruin (about 2/3 of your usual wages) and keep you from losing your job for being injured.

During the industrial revolution and until about 100 years or so ago, if you were injured (cut off your arm, broke your back, etc. . . . ANY injury) you were shown the door, escorted sometimes to your company housing, where you were thrown on the street after being handed a bill for rent and your tab from the company store, and you were responsible for sewing your own arm back on or fixing your broken spine the best you could. Back then there was not even health insurance, so you really were out of luck! (I did my senior thesis on the Pullman Car Company of Calumet City, IL, where I learned these things happened all the time.)

So if your benefits and your hassles with your claims person seem too much, just appreciate what history stands behind you. Then learn about your particular state's claims process the best you can. Many injured workers went before you, blazing a painful and costly trail to this time in history.

W/C is not meant to make you rich. You will go backwards financially a little, even though you get a check each week or two. However, your medical should be paid at 100%. If you are ever billed for something that w/c should cover, turn the bill in to your claims person. If you are ever billed for a balance after w/c adjusted the bill, this is a violation of the law. . . tell your claims person!

For now let me just say a few things that are basic good claimant (that's you) etiquette:

• Be polite, calm, rational and businesslike with your claims person, the doctors and anyone regarding your claim. It will move you farther than being the opposite: threatening, belligerent, angry or pushy.

• Do all your paperwork promptly. There may be a reason something gets delayed, but your claims person can only act on what he or she has in the file. A common slogan among claims handlers is: If it isn't in the file it didn't happen. This is why I recommend following up every important phone call with a letter: you may need the paper trail later. Keep a file and keep copies of every letter you receive and write, every notice, note, and some even keep copies of checks (or the stub to show what it paid) . . . and a log of your phone calls, in the file.

• Learn to use your word-processing program, including spell check, so your correspondence will be businesslike. If you don't have a printer, see if you can e-mail your correspondence.

• Find out if you can protest any unfavorable decisions and follow the timelines. A day late and you lose! A protest is not hard to write. . . the statute will often give you the format and the words to use, or close to that.

• Do not skip doctors appointments or skip treatment. Like all medical treatment, you have the right to participate in your treatment plan, to a great extent. If you are unhappy with your physician, therapist or counselor (if you are in vocational counseling) . . see if you can change. You can refuse a treatment that is against your beliefs or better judgment, and you can not be forced to have surgery or other invasive procedures against your will. However you must have a good reason, and be prepared for your claim to be a little more complicated if you refuse, say, a surgery that could return you to work with low risk, or an test that could move your healing forward.

• Do not lie. Do not cheat. Do not fake. Do not try to get away with being off work if you are truly not injured. Claims people hire investigators all the time, even on "nice" people. Sometimes it is the protocol for handling claims for a particular company, or standard claims handling practice for certain types or levels of claims. (I once won a case forcing the "injured" worker to repay over $84,000 because we caught him doing heavy farming activity when he claimed he could not turn his head to drive or lift a gallon of milk. I saw it on the surveillance tapes myself!)

• While you must adhere to your restrictions, you are allowed to shop, and take care of your kids . . . and, yes, you may leave the house while on total disability! You probably want to stay away from the roller rink, the softball game or even the fishing boat on a holiday weekend, depending on your injury.

• It is believed you get your way by piling up phone calls and messages to your claims person. If you have to go that far to be heard, ask for their supervisor. Follow up your first call with a letter, and copy their supervisor or the manager. When their file is reviewed it will come to someone's attention you have not been answered . . . and someone should get a reprimand for ignoring you. If all 200 claimants called me every day hounding me for checks that are late, for information, or just to talk, I would never have gotten anything accomplished in a day! Remember, they are doing their job to please their boss, just like you have to when you are at work.

• Keep in touch with your employer so they know a) how you are doing, b) if and when you might return to work, c) that you are still an employee (do not abandon your job mid-claim, it makes life messy later) and d) it is the correct way to keep them onboard with your claim. That way they know you are earnestly trying to get well and return, and will see you more as a returning asset than a present liability.

• Stand up for your rights. If something seems amiss, ask. Protest when you feel a decision or action is wrong. Stay on top of your claim. Start a file and keep everything in it in some form of useable order.

• Return to work when you are released. If it does not go well, or you flare up your injury, your doctor is the one to document the medical reason you can not continue, and might need more treatment. In fact, your doctor must provide documentation for almost all of your benefits: time loss, restrictions, treatment, and return to work, as well as when healing is complete (maximum medical improvement, end of healing period, or whatever it is called in your state) and permanent impairment.

• Make sure impairment is addressed before claim closure.

• Find out what the statute of limitations is for reopening, and under what conditions this claim might need to be reopened.

• Understand that in many states if your injury is the same as one you have years ago with another employer, you may be asked over and over for a work history so that they can see if some of the costs should be thrown back on the previous employer's injury. Every state seems to handle pre-existing injuries or conditions differently: find out early how your state handles it. Then don't spin your wheels trying to fight it. Only cases that are hard-fought in court change laws, and unless yours seems that strong, concentrate on getting all your benefits that are due under the law. Unfortunately that can sometimes be harder than just going back and doing your job!

• Of you qualify for FMLA, file for it! You have approximately 12 weeks of protection of the job you were in at the time of injury, or a substantially similar position, under FMLA. Unfortunately, if you use FMLA for your neurological condition, you may have to share that 12 weeks with your condition . . . you only get so much time under FMLA regardless of how many conditions you use it for.

• Do not compare your claim to anyone else's claim. Rarely, if ever, will two injuries, severities, wages, hours, and employers be identical, let alone doctors, details, outcomes, or "settlements." . You are wasting energy wishing you would get the big "settlement" your neighbor, friend, or second cousin on your father's side did! This is a cruel trick you play on yourself if you listen to everyone else's expert advice, because they had a claim or knew someone who did. Run, don't walk, to the nearest earplugs. Tell them how interesting you find their information. Thank them. But do not ruminate on what they claim or believe you should be getting. It is almost like saying every lottery ticket is a big winner. It just ain't so. Some claims, and rightly so, close with no big jack-pot at the end.

• I strongly object to the term settlement when discussing workers compensation. Being a no fault system, if you are permanently impaired or disabled by your injury, you are entitled by law in most if not all states to an award of permanent disability benefits. This money is to compensate you for future medical needs that might be consequential or might arise later (such as prescriptions, they are not generally covered after claim closure), but not be sufficient for reopening. It is also to make up for a possible drop in your future earning capacity due to your loss of function in the work place. It is not a windfall to be spent on a new 4x4 or vacation, unless you have an endless income stream guaranteed in your future. I suggest you buy a few certificate of deposits and sit on it for as long as you can. It might come in handy down the road when you get laid up with a non-work medical condition and have no or little income, or when you can no longer do your job and find you are earning less. That is what it is designed for. Honest. But I bet over 50% of the checks I cut were "blown on stuff" before the ink dried on signature on the back of the check.

Sometimes the final payment, if it is more than a year's worth of benefits would be, are paid out in monthly amounts. If this happens, be glad you have an extra check each month to put into savings after you get back to work. Don't sell out to one of those companies who will give you cash now. You will get less than you are due, because they will pay you at a discounted rate, and they will walk away counting your money as it enters their pocket. They may be legitimate, but they are immoral by preying on people in dire need in my book. If you are hard-pressed for money when it comes time for your final permanent disability payment, and it is set up as monthly payment, ask your employer or claims person if you can have a hardship lump sum of all or part of it.


Well . . I am up wa-a-a-ay past my bedtime. If there are any questions, ask away. I will discuss permanent total disability if anyone is in this situation. Sometimes it is called a W/C Pension. They are rare, hence I am no expert. But maybe I can help if you have questions I can answer or give you a direction to go for answers.

For now . . . good night. If I have any typos or misspellings. . . . it is 2:37am here right now. . . .


"Z-z-z-z-zz-z-z-z-zz-z-z . . . . . ."

[Jomar]

I think most have problems with the system when they have a 'hard to prove" injury.
Something that does not show on a xray or Mri or other concrete tests.
Or if they cannot find a dr that is fully knowledgeable in whatever injury they have?

If you can share some tips on how best to deal with the wc system when you have a chronic or difficult claim?

I know my claim was kind of messed up - because I trusted the system, and I assumed the atty, the drs, etc to knew what was supposed to be done.
I didn't really have clue back then.

[lefthanded]

Jo55 said:

If you can share some tips on how best to deal with the wc system when you have a chronic or difficult claim?

I know my claim was kind of messed up - because I trusted the system, and I assumed the atty, the drs, etc to knew what was supposed to be done.
I didn't really have clue back then.

I understand, because even with my experience we were unable to get my partner's COPD claim allowed as an industrial injury. She had never exhibited any signs of asthma or lung issues, including she never had bronchitis or pneumonia in her entire life. However, after working a couple years at her new employer, following her period of unemployment during my surgeries and recovery, she developed bronchitis and pneumonia which was followed by asthma. Her place of work is an extremely dusty environment, which would be like working in a chalk factory where they grind the mineral into fine powder right there before forming it into the little sticks. (This is not what she does, but a spot-on analogy . . . I don't want to reveal her employer, as her claim is ongoing. She essentially works with the same materials, and comes home dust covered almost every day.)

She now uses two types of inhaler and takes oral meds as well as prednisone when it flares up. But the independent doctor said it was only an aggravation of her preexisting asthma and not brought on solely by the dust at work. We know that is bull, but even her own doc agreed! Short of hiring our own lab to to air sampling (Labor and Industries will only do this if they think they will find a toxic substance, but copious amounts of dust don't matter!) and pulmonologists to evaluate her complete medical history, which we would have to ay for, and hire and attorney, we were sunk.

So I understand the challenge of, say, TOS which is either caused by repetitive movements at work, CTS, which is both work related and can come on in mid-life and later without work aggravation, back issues, etc. I have handled them all. The sad part is if the employer is self-insured, in many states they can be, they are usually more responsive to these kinds of claims and injuries. I know her claim had better chances of being an ongoing, work-caused claim if her employer had been self-insured. The state might have practically forced them to accept it, but the state operates here by complete different standards. I find this reprehensible, ad two people, one who works at employer A (state fund) and the other at employer B (self-insured) get completely different handling of their claims. i wish I had the power to work to stop this. . . .


The best advice I can give is that you never want to rely on anyone handling your claim. This is not about trust so much as being able to manage your claim as much as possible. This means you find a doctor who will support your claim, (or give you a good, clear explanation why it might not be covered.) However, if if it is not found caused by work, you might still be able to say the aggravation was caused by work. Then this is where you will have to direct all of your efforts, to prove that work is making your condition worse or not allowing it to get better.

I am sorry that there are health issues that are either caused, aggravated by, or arise during one's work life that are not found covered under worker's compensation. The program initially was set up to cover accidents, and over the years has evolved to cover other illnesses, like black lung, etc. Even today attorneys advertise for clients for some of the difficult lung issues, which indicates to me that workers still have an uphill battle proving work caused their illnesses.

That said, each and every person here with a difficult diagnosis, and a correspondingly difficult workers compensation issue, would need an individual evaluation of the situation. This is because, as I have said, every state's laws are different, and every employment is different, and every worker's physiology is different.


The steps I would take to approach filing a claim for TOS (I have handled several that were covered back in Iowa) or other repetitive injuries, would be:

1. File the claim with an onset date when you first noticed symptoms. If the statue has passed it is likely you may only get an aggravation claim with a more recent date date.

2. Gather all the medical history on yourself that you can to show you were never seen or treated for this condition before your work for this employer. If it began with a former employer, but continues to be aggravated by the current one, you may have to file against both.

3. Gather job descriptions from each task you perform (or performed, if a prior employer), with specific details as to the physical requirements and the amounts of the repetitive activities you do that you believe caused the condition.

4. Get medical testing that defines the nature of your conditions. I believe TOS requires some kind of Doppler exam, as well as x-rays or other means of pinpointing where the impingment is.

5. If the claim is denied, I believe it may be in your best interest to hire a good attorney who specializes in the condition you are filing for. Hiring a friend or you own personal attorney is a waste of time, and if the attorney you do hire finks out on you, fire them and look elsewhere. We have experienced this personally, with an attorney who held our file for review right u to the deadline then declined to take the case. Gr-r-r-r!

I know the above sounds like something the claims person should do. . . but they have been known to include only that which will support their position, and sometimes doctors even leave out incriminating information. Record will cost you, but it is often worth it.

The hardest thing for me to say is that it is always possible that the facts and records and symptoms simply do not compute to enough convincing evidence of an allowable claim no matter what you do. TOS, CTS, and many spinal issues carry that "normal aging" curve with them, that medical "don't know the cause" reputation, and are resisted as work related with great frequency.

The "system" was originally set up to allow filing of legitimate work injury, but over time it has been fraught with the reputation of being rife with fraud, unfairly hard on the employer (I say, what about the worker's bodies?), and an expense that must be reduced or controlled by any means possible. The ergonomics laws passed in the 90's have been so watered down or eliminated by disuse that we do not see the workplace evaluations of potential injuries that were intended to come out of the legislation.

Another factor that doesn't help is the political climate we live in. I believe beginning with the onset of big breaks to industry when they began whining about profitability, we saw a steady decline in their responsibility to the workers of America. We are back to being machines parts, expendable and replaceable. Rare is the employer who truly cares, and whose corporate structure includes safety and prevention on a large and honest scale. Most do it to front the impression that they are complying with any applicable laws. Hopefully we will see a change in this as the political climate warms under a new administration.

Imagine how universal healthcare might alleviate this. At least the treatment part. I envy workers in some European countries whose employers insist on taking care of their employees. I am afraid with our influx of workers willing to undercut everything in our system -- wages, living standard, working conditions -- we do face an uphill battle.

I will do what I can to help. W/C is not cut and dried. Being an examiner has some horrible stressors attached to the salary: we had to close claims to get paid for our work, we had a greater workload than we could handle (and we had them by client, and I had some of the tougher clients), there was constant pressure by the clients(employers) to reduce costs, and every one of our files had to be highly detailed and in perfect order (a full-time job in itself), and we were expected to sit in b.s. meeting that were no more than marketing for our service providers (nurses, vocational counselors, attorneys). In an 8 hour day were we supposed to review all diaried files, return all phone calls, monitor all medical and legal aspects, make sure all checks were issued (very important) and file an endless stream of paperwork with the state or suffer penalties. In addition, some phone calls would take much longer than average, and we were always ridden to cut them short. However it was my philosophy that if I explained claim issues to a claimant and listened to their frustrations, I could help avoid issues by increasing communication. Think so? Heck no . . , I was always under scrutiny for spending a little time with a hurt worker rather than giving quick replies and hanging up!



Enough about why claims are frustrating and why your claims person is not warm and fuzzy all the time. Enough about the reality of claims. If anyone has a question I will do my best to help you find some answers. . . . .

[lefthanded]

thursday asked me to repost this response to her "Sweating over claim closure," so bear with me, some of it might be repetitious:



I was a Senior Claims Examiner with over 13 years of experience in worker's compensation in several states before my last employer put me on disability. Let me preface by saying every sate is different. I urge anyone on W/C to read the basic on how your state's w/c works.


A claim will stay open as long as your doctor can document that further treatment will improve your condition. Once he can no longer justify your being in treatment (even if the physical therapy, etc. keeps you from sliding backwards), you will likely be declared fixed and stable. At that point your claims examiner with do one of several options: a) prepare the claim to be closed, b) request a permanent disability evaluation from your doctor, or c) set up an independent medical evaluation for determination of permanent disability and/or restrictions.

I advise anyone nearing claim closure, that unless you feel just as healthy and fit as you did before your injury, and sometimes even if you do, request a permanent disability rating from your doctor. If he can not do one (not all doctors have the certification to do this) ask him to refer you to a doctor for a consultation for closure and determination of permanent impairment.

A permanent disability or permanent impairment rating should take into account all factors such as loss of strength, loss of range of motions, loss of sensation, residual pain, your age, and perhaps even your physical condition, and your education level. If your hand is injured, ask that your rating be to the arm, if your thumb, to the hand, etc. If you have a back, shoulder or hip injury it should automatically be rated as loss to the body as a whole. However, remember, your state may vary somewhat . . . but you can ask for a copy of the statute on disability/impairment (they are the same thing) ratings.

I urge you to not let your claim be closed without addressing permanency unless you truly feel so fully healed that you can not imagine ever having the injury site give you any grief as far as being able to work. Disability is rated with regard to ability to work, not with regard to bowling, playing golf, or climbing mountains or skiiing! (I have had every question in the book asked of me regarding sports and activities that a claimant could no longer do.. . . but unless it is a work activity, your industrial injury is most likely not going to be responsible.)

You will not get rich from your permanent impairment rating and award. It likely will seem like a mere pittance for what you have been through, unless you have suffered a severe injury like amputation or a severe head or back injury, requiring major surgery or extensive rehabilitation. if your rating seems too low, ask the doctor to explain how the figure was determined. If the state arranged your independent/rating exam and it seems unfairly low, ask for a second opinion, with your own choice of doctor.

Carpal tunnel surgery never used to carry an impairment, as it was believed surgery restored 100% function, but that was changing when last I worked. Fractures of the arms, hands, legs and feet should be rated for impairment, as should back injuries with residual pain and/or loss of flexibility, even if you did not have surgery. Hearing loss always has impairment, as does loss of sight, taste, or any of your senses. I once paid impairment for a claim for loss of the sense of taste when the treatment for the injury caused the loss, even though the injury itself did not. I also paid out a huge claim on top of the work injury when a therapist treating the work injury dropped a patient and cause paralysis! (The additional costs for the second injury went to subrogation, meaning the therapist was responsible for everything over and above the initial injury . . . but it was messy, as the patient was not nearly to the end of her treatment when the therapist dropped her!)

(Speaking of subrogation, if a third party is responsible for your injury, they will have an interest in what is paid out on your claim. However, do not let them have undue influence over the claim, or push for closure, early end of treatment, or less treatment than necessary. And do not deal with them directly . . . your employer or the claims person is responsible for dealing with this.)

The best way to deal with your claims person is to be calm, reasonable, not angry or upset, and to educate yourself as best you can, as this will get their attention. The worst thing you can do is threaten, act like you are or have an attorney (your ability to talk directly with a claims person, and sometimes even your employer, about your claim, ends when you get an attorney), or indicate that you expect to "own the company" once your claim is settled. Believe me, I have heard it all where closure, money and punishing "bad" employers and their representatives are concerned.

I used to tell my claimants who asked up front if they would need an attorney on their case: "not if I do my job correctly." And then I would tell them if at any time they feel they can no longer get what they think they need from me or the system, then that is when they might want to speak to an attorney. Fees can range from flat-rate hourly with the clock ticking on every phone call, even the ones that are not returned (number one complaint about attorneys is that they do not return client calls on w/c claims) to anywhere from 20% to 30% and more, plus expenses/costs. Some of the best reasons to get an attorney are:
1. Your claim is denied and you truly had an on the job injury. Not an accident, but an bona fide injury. An attorney will know how to best present your case before whatever review board your state provides.
2. Your claim is only allowed for part of the injury and you or your doctor feel that your injury is greater than what was allowed.
3. You are refused benefits and you have been unable to protest them out of your claims person. Remember, every order issued to you is likely able to be protested in writing. Learn to write a decent and neat (with spell check) business letter. It is beeter then righting one that culd make them laff and not take yu seeriusly.
4. Your claim is closed before you have finished treatment. Your doctor should protest this, but if he doesn't convince them, you might need an attorney.
5. If, in your state, your employer/claims person has the right to dictate which doctor treats you, and this doctor is seriously downplaying your injury, an attorney might be needed.
6. If your claim is closed without a disability rating and your claims person disregards your second opinion doctor's rating. Attorneys love ratings cases because they know approximately how much money they will make and have to spend to get it.
7. You have not received all of your time loss/loss of earning power benefits and your examiner closes your claim. After you have submitted a protest with your calculations, if you still feel they owe you for lost time or lost income benefits, you may need to get an attorney. Included here would be if your time loss rate was not calculated accurately, or does not include shift premiums, overtime or bonuses in the calculation. However, these usually must be protested within a specified period after you have received an order for payment and calculation of benefits. Do not miss this deadline . . or any deadlines, for that matter. You will be left out in the cold!
8. Your employer does something that appears to be retaliatory for your filing a claim. e.g. Your employer fires you for filing a claim and ruining their perfect no-injury record, or they treat you differently when you return to work, like forcing you to take a job that pays less even if your job position is available, or move you to another shift when there is an opening on your regular shift. This is a fuzzy area in the law, which is why you should at least ask an attorney if you feel any kind of discrimination or retaliation, and especially if it is for filing an injury claim.

This list is incomplete and may not apply to all cases in all states. I have tried to provide a summary of ideas to help you educate and protect your rights when it comes to on-the-job injuries. Learn if and how to protest any actions you feel are not timely or done improperly. Learn to speak up and stand up for yourself. It will feel like work. . . but hey, you are getting paid something in the neighborhood of 2/3 of what you had been earning before you were injured. Get to work protecting yourself!!!
__________________

[diaba]

Hi Lefthanded, maybe you can advise me on my situation. Neck/back strain at work last Oct. Still with residual tingling symptoms that travel from back to front of my head, and intermittently in left arm.

w/c doc feels symtpoms are not related to work injury anymore(I also have MS)so they're no longer paying me or allowing me to work modified duty. MRI shows no new flares and my neuro and primary doc don't think it's the MS. MRI of neck shows minor disc changes.

So I requested a QME, the claims adjusters say I have to see a neuro QME to confirm it's not the MS. They don't want me to prove it's related to my neck injury, I need to prove it's not the MS(thought I'd done that already).

Anything else I should be doing. Thanks for your help.

Diana

[lefthanded]

diaba . . . . have your neuros and primary physician submitted reports stating that they do not find any MS relationship to your current symptoms? Especially helpful would be records that show you have never experienced these symptoms with your MS. If your MS ever caused any symptoms like this, though, it may be pretty-darn close to futile trying to pin them on the injury.

It is to be expected in W/C cases that any residual symptoms will likely be pushed off on any pre-existing conditions. This is the game phase of your claim. I gotta be honest, sometimes you win, but more often than not you get your hopes up and they win. I can only explain this by saying -- power lies where the money is. When it comes down to it, they will hire big-bucks lawyers.

See if you can find a neuro who will read all the records. Someone with MS experience, big time. I would also ask if you could be privy to a copy of the questions asked the QME doctor, and what records he uses to make his determination. This may not be all that simple. I wish I could give you a magic formula. I would say it may also be time to see if there is an attorney good in both comp and ADA. An attorney can often make sure the records are not an abridged set, skewed to get the result they want. However, you do want this to be a clearly independent exam, too, or if it ever makes it into a court room, it will lose water for being biased.

Was your employer making any ADA accommodations before the injury? If so, and you do lose the residual symptoms case, then perhaps they will still have to look at reasonable accommodations for your "new" MS symptoms of tingling of the LUE and head and neck. I would push for accommodations if you do not prevail on this issue in your W/C case.

This case really reminds me of my partner's case, where they agree she needs a respirator, but deny that the dust at work was the proximate cause of her asthma. They allowed your neck strain, but "NO!" the neck, arm and head symptoms you never experienced before are your MS. I totally understand the frustration.

I don't know a great deal about MS, nor what kind of work you do. But the fact that you are(were?) working and doing work sufficient to cause a neck and back strain speak well of your intent to be a productive employee. And you didn't say whether any of the doctors feel that these symptoms may dissipate with time or not. If they do, then it would not seem you are at medical stability or maximum medical improvement. It this is the case, it seems their decision to withdraw offers of light duty work and pay are premature. However, I am aware that in some states MMI and healing period are not as strong concepts as in other states. Each state also seems to have a different take on how to handle pre-existing conditions. Some factor them into the injury equation, making allowances when they slow healing, return to work, etc. Others just discount the disability by the corresponding disability of the pre-existing condition.

In many claims I have handled in the past (way past) I recall IME wars. . . .files that were enlarged almost weekly by the battle of the doctors opinions. This is just sick, and a waste of money. So is fighting an employee who wants to work. But I am afraid often times the employers are not that enlightened.

I hope that your doctors can garner the data and medical evidence to refute that your residuals are due to MS. It sounds to me like you understand the nature of the battle you are in. I am sorry I couldn't offer something very new here . . .

[diaba]

Hi lefthanded, thanks for your input. I'm a PT who works doing a fair amount of patient lifting. I didn't have any accomodations prior to this, they didn't even know I had MS, and my symptoms are new. So I'll wait and see what happens next. It's been an education, that's for sure. Thanks again!

Take care, Diana

[sandi_k]

Lefthanded:

Thanks for your expertise; it's very useful to read! I have two questions for you (I just had my second QME yesterday).

1) I hired a lawyer a year ago, when I first got the MRI results showing spinal cord impingement by a LARGE osteophyte, and my employer's orthopedic surgeon said it was 90% work-related. The spur is at C5-6, so in a very BAD place. I want a neurosurgeon to at least be a surgery partner, in substitution for or in tandem with, their orthopedic surgeon. In CA, to your knowledge, do I ahve the right to demand a neurosurgeon?

2) I now have 3 out of 3 drs. (who have seen the MRI) agree that I need surgery. If I NEED it imminently (before the legalities are ironed out), is it possible for me to have the surgery regardless, and then have either myself or my regular health insurer SUE the WC organization to recoup costs? I'm afraid I may have to delay care due to concerns over who pays for it...and that would not be in my best interests.

Thanks.

Sandi

[mrxtramean]

I'm from Oregon and I'm an injuried worker. I'm fighting our so called "trailblazer" workers' comp system. Oregon is said to have one of the best workers' comp. laws in the nation. But, in my opinion, best for the insurance/employer and not the injuried workers.

I will soon be putting up a website to help Oregon injuried workers' at oregonworkerscompensation. net. I have lots of information, but at the moment, dealing with my own case.

I had a lifting injury in 2002. Extruded, free fragment, herniated nucleus pulposus at L5-S1 with lumbar strain. I filed for aggravation in 2007 and was denied.

For all injuried workers.
1) Get an attorney asap. It does not matter how bad your injury is, get one.
2) Ask multiple physicians, a physical therapist, a chiropractor, your primary care physician and your specialist (if you had one), "What can I expect my condition to develope into in 2-5, 5-10 years? Is my condition degenerative now or will it be? What should I do to protect me from future 'worsening' of the injury?"
3) If you have a herniated disc, your disc motion unit ( www .chiro.org/Vertebral_Subluxation/Anatomy_101.shtml) will degrenerate faster than normal. In my opinion, this is what the claims examiner/insurance co. hope for because then they can deny your claim for aggravation based on injury not being the "major contributing pain factor", it becomes a "pre-existing injury" and a "combined injury". You should get the attorney, if possible, to get claim to except "degenerative disc disease". It's not really a disease and the classification needs to be changed. I'll much to say about DDD on my website. DDD is a "catch-all" phrase and the pain from which the IME (independent medical examiner) says you have may not be from DDD but from a multitude of conditions.
4) Read your states law on workers' comp. and it's statute changes.
5) Have your doctor log everything! If it's not in the medical records, then it's harder to prove.
6) Claims examiners work for the insurance company, from which your employer has bought a policy from to deal with their injuried workers. The claims examiner, in my opinion, is not the "good guy/girl". They do not work for you, but against you. With that said, my claims examiner is nice, but she still works against me.
7) Doctors suck. Many do not want to deal with workers comp claims, many do not want to take the time to deal with direct issue's because they're too busy following "medical guidelines/protocol". A private doctor might be your best choice, as they will be able to focus more in details. A clinic doctor gives your 15 mins, is too busy with patients. And for hearings, a specialist will provide greater "persuasive" weight against the insurance companies IME.
8) IME's are supposed to be "un-biased", but when they are paid, like mine were, $13,000 between the 2 IME's and the office visits for both were under 90 mins, you know you will not get an "un-biased" examination.

I applaud you lefthanded for trying to help. Injuried workers are blindsided and left to think all will be well when their claim closes, but that's not the case. In many cases, like mine, depression, stress and on-going painful conditions will limit your range of motion, life qualities and your ability to function like you did prior to your injury. Just be aware of this and ready for it.

Lefthanded, tell injuried workers what they really need to know to get the help they need with their present pain/injuy and their future aggravation conditions.

Thank you, MrXtramean. No struggle, No progress.

[lefthanded]

mrxtramean, I agree that Oregon has an incredibly regulated and tight w/c system. . . .I once looked into working as a claims person in their system, and decided my own mental health would not permit me to do so! I don't recall now just what all the rules and regs were, but that the amount of oversight by the state is incredibly oppressive.

Please, do not believe that just because you have experienced a claim as an injured worker that you can just "hang out a shingle" on the internet and start advising other workers. It takes a good deal of education to understand the ins and outs of the laws, the history, the whole arena of risk management, and lastly, claims. I have been through numerous and highly specific claims training classes, both in comp and liability, even a little malpractice, and have a year of law school as well. All that makes me is "dangerous." I never hold myself out as an expert. . . just someone with experience that many do not have, information that most do not have, and some good stories that may net me a free drink at a cocktail party now and then!

I understand your fears, frustrations and anger at the system. However, the belief that an injury should mean that the employer should be on the hook for every ache, pain, twinge or problem in the future is based more on wishful thinking than it is on REALITY. Workers compensation is designed to make sure you have an income while you can not work, that you get adequate care (this is often the language of the law, meaning no, you don't get to travel across the country to a specific doctor for your injury), and your claim will not remain open for years and years and years until you are sure you will never have any additional issues.

Insurance is sold by a rating system, and employers would be out of business if claims were open indefinitely. An employer often has a level of self-insurance (aka deductible) for each injury, and they must set aside reserves of money that correspond to a guesstimate of what their total claim costs will be. If an employer were never allowed to close a claim, those reserves would grow each year as new claims occur, and eventually there would be nothing left for overhead, salaries, benefits or capital improvements. In effect, w/c would bankrupt the employer, and the workers, injured or not, would be unemployed.

However, I do agree on these points:
1. If you are injured, by all means, learn how your comp system works in your state!
2. Make sure your doctor documents everything correctly. Also have your doctor explain your injury thoroughly.
3. IME's are so badly abused that in some states they have limited their use and scope. However, I have seen IME's nail an employer for an injury they tried to resist --- they are not all BAD doctors or BAD exams.
4. An injury can be complicated by a degenerative condition. But most states do not allow for the entire package (injury + degenerative changes) to become your employer's responsibility, even if you never had severe issues with the degenerative condition.
5. Many doctors seem to have forgotten how to take care of patients, because they have so much else to deal with, including regulations about documentation, continuing education, and malpractice premiums among them. Their time with patients seems to have been compromised by the requirements insurance companies put on them to get paid.
6. While it is true claims people are employed by the company, the state laws usually regulate what they can and cannot do. Some companies push for denial, while others push for compliance with the laws, and others for reducing costs within the law.



However, I suggest you put yourself in the shoes of an employer for just a second. Imagine your own money on the line, and the hundreds of employees you have working for you as income and expense columns on your books. At the end of the year you want a balance between making a product and having a little profit from which to take your own salary or means of living, and paying your workers, their health insurance and other benefits (sometimes over $1000 a month for each, when you add up medical, dental, vision, vacations, etc.) AND paying not only w/c premiums but also claims costs. Before damning the entire system as evil, do remember that w/c really is a system meant to relieve the burden on the injured worker, but not designed to alleviate all issues.

And count your blessings that you do not have to sleep on the ground in a campground right out of a back surgery because you are homeless, like one of my claimants did. Or that other medical issues, totally unrelated to your work injury, caused horrible delays in your treatment that meant you would not recover as well as if you had been healthy otherwise, like another of my claimants. True, you should not have to fight your employer for an injury that is clearly work related. Unfortunately, there are those employees out there who have faked and frauded their employers to the point of making them suspicious of everyone who files a claim.

I had a guy who actually asked me how much more he could get if more of his fingers were amputated. A quick check of his claims history revealed a pattern of suspicious claims that were essentially whittling away at his dominant hand. Before each claim we found either a bad review at work or other evidence he was after all he could get from his employer. Too bad for him that it was only money to them. . . he was the one left with deformed hands!