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Layoffs, Unemployment and Worker's Compensation For discussion of any topic related to one's employment and unemployment, worker's compensation, and job.

I have 13 years w/c experience and was senior claims examiner when I became disabled

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Unread 06-01-2012, 09:21 PM   #81
lefthanded
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Originally Posted by picobill View Post
Lefthanded, I can see from your posts that you really believe in the System, Sadly I cannot afford to evtend my belief that far, I must deal with the System as I see it.

...

Sorry long as this post has taken me and much left unsaid but even with breaks my hands are on fire... positive side.. my PT for the day is done.. Please take no offense this is how I see the system. BTW I'm left handed too
I absolutely agree that the system is broken. It didn't break on its own, either. The original GOOD intents have been eroded in the same way worker's rights and union protections are being chipped away today. Same with healthcare. The problem is profits . . .

When I first became an adjuster in Iowa, we as claims adjusters had complete control. We chose the docs and we authorized the treatments and we paid the bills. We had the power to deny claims from our desks.

I always worked with self-insured clients, those who retained a huge "deductible" (usually between $10,000 -50,000) before the insurance company would get involved. Employers with that much power believe that claims should be handled as they see fit. Many times I got called on the carpet for putting injured worker's needs first. The pressure to deny, reduce, close claims prematurely was certainly a constant battle.

then along came "case management" ... almost always done by nurses and counselors employed by the insurance company, billing hours to the claims for "cost saving" measures . . . . which rarely if ever saved as much as they cost! But the profit from handling claims rose, because billable hours are billable hours . . .

The system is broken and yes, there are many claims people who just follow the company line. But there are many who actually would like to see injured workers treated for their injuries and compensated when they are left less than whole.

And I totally agree about IME's. I used to pick docs I would have agreed to see personally, but even then sometimes you get garbage. I also filed many complaints about IME's . . . even when doing so meant pissing off people I had to work with every day. I don't know when IME's started trumping AP's . . . that is a travesty unless a quack is providing the worker care in the first place.

But even with all that acknowledged, W/C is still better than nothing. Not having unrealistic expectations and knowing how the system can work is your best defense. One truth most injured workers tend to ignore is that your worker's compensation claim is not a guarantee that you will be good as new. Too often the anger I would face would be because the worker expected to be made 100% whole. PPD awards do not replace that wellness, but it is the best we can do. And no two bodies -- or injuries -- are identical.

I have watched as my own partner has been screwed by the system, regardless of what I have tried to do to help. Her COPD is from pre-existing asthma (never any prior history or diagnoses, ever, before working in a dusty environment); she can only file for temporary aggravations. The IME doc ignored her records . . . I was there! Currently we are fighting for PPD not awarded in a closed claim, when the medical report specifying a category rating was right in the closing medicals! The adjuster said she "must have missed it." Now we have to sue for it. What a crock. I hear ya.

The best advice I can give is keep great records of every incident, every thing that happens during your claim, and every conversation. Treat being a w/c claimant like it was a career. Learn your state's laws as best you can. And try to always be polite.

I violated that one one. I suggested an angry claimant might want to "park her attitude" when she was chewing me out for something another adjuster did before me on her claim. i was overheard and written up. I wanted to tell her to shove it, she was being so rude to me, so I thought "park it" was a milder way to slow down the discussion. I was wrong. I apologized. So did she. It goes both ways.
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ginnie (06-02-2012)
Unread 06-02-2012, 07:55 AM   #82
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It is legler and Flynn, with Mr. Benjamin on Manatee avenue in Manatee county florida. 941-748-5599 . This gent stuck with my case, and did not give up. ginnie
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Unread 06-02-2012, 07:58 AM   #83
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Default Hi Hybernating

I am late to some of the talk on the forums too. I also have a personal friend who is a phychologist that would talk to you on e-mail if you need help. Hope Mr. Benjamine can help you with your claim. The system is broken, of that I have no doubt. Just don't give up hope. ginnie
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Unread 06-03-2012, 06:45 PM   #84
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Default Can work comp make you change P/T?

I copied this to a thread of it's own - here-
http://neurotalk.psychcentral.com/sh...d.php?t=170955



The doctor who first examined me for work comp (their pick) sent me to physical therapy. Great therapist but I saw him only once before work comp called & said I had to go somewhere else. Can they do that if it's someone their IME assigned? I have TOS & a cervical rib - first of all P/T isn't going to do much for that & 2nd it's rare - I seriously doubt the storefront outfit has even heard of it.

I live in Omaha, NE. If anyone knows of a good doc for TOS in the area, please let me know!

Many thanks,
Mary

Last edited by Jo*mar; 06-04-2012 at 12:16 PM.
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Unread 07-25-2012, 09:17 AM   #85
happiedasiy
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Default wc help

I am new to nt
I am permanently 100% disabled due to work related injuries.
So I came here to see if there is any new information out there or if I can be of help to others.
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Unread 07-25-2012, 10:23 AM   #86
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Welcome to Neuro Talk. We need you! Many people come here looking for information and help. I can't tell you how many people there have been for direction, hope, some kind of support. NT needs good people all the time to pitch in and give folks a fighting chance. Thank you for coming here. You will meet alot of friend here too. I have stuck around for two years now, just love the site, and the people I have met. Again welcome, feel at home, hope I get to know you better in the near future. ginnie
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Unread 12-05-2012, 06:14 PM   #87
megashark2015
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Default Neck injury, QME, disability rating

Hello,

I worked at the same company for 9 years with broken office chairs. I kept asking for new chairs, I brought it up at every staff meeting, submitted requests in writing, I was told it was being considered, but it never happened.

I was the supervisor of 3 people, one counselor was behind on her files, I asked her to get caught up before I went on vacation at the end of the week. Half hour later she came to me stating "I'm under too much pressure, so I went to the director to quit, and the director gave me a 2 week leave of absence." She then walked out and left me holding her 30 files that had to be closed out in 3 days.

I got to work on it, in my broken chair, I was under a great deal of stress, I was leaning forward, I felt a pop in my neck, then searing pain, then my left arm, left side of my face went numb and a spasm underneath my left eye started. I filed a workers comp claim (05/31/11).

I was very dedicated to my job, so when the Dr asked if I felt I could still work, I said I could, and have not received any disability payments.

My official diagnosis was: disc degeneration, stenosis, narrowing of the chord, were all aggravated by spraining my neck the date of injury. I received acupuncture, physical therapy, and when I was referred to a surgeon to discuss an epidural he said the only thing that would help is surgery (which I declined). That was in January 2012, I moved south (200 miles) and I never heard from workers comp again. I have been living with chronic pain since this all began, I have difficulty performing the work I once did. I planned to contact my claims adjuster to request medical treatment, but then I received a letter from her requesting that I see a QME. She stated I could still get treatment, but wants a QME. She approved me to see a physician about my injury, but insisted that I also pick a QME. I didn't know at the time that no new physician will see me if my QME is already scheduled, so I didn't get to see anyone about my searing pain, which seemed pretty wrong of my claims adjuster to mislead me like that. Anyways, she said my primary physician never gave her a final physicians report.

So I saw the QME Dr, as I was trying to tell him my story he kept his back to me and continued to cut me off. He seemed very much in a hurry to be done with me, and expressed the "inconvenience" of the appointment. He didn't have any of my MRI/XRAY's on hand (he noted in his report that he will re-evaluate if those are provided) and said he couldn't give a full evaluation without those. He had not reviewed any of my medical records so he actually asked me what I was there to see him for!

Today I recieved a copy of the report he sent to workers comp:
He states I had pre-existing degernation/arthritis/stenosis (non-industrial)
He states it was aggravated by a neck sprain (industrial)
He states I received adequate medical treatment (maximum medical improvement)
He states the extent of my injury is unlikely to be caused by leaning over.

He states I am
0% industrially disabled
100% non industrially disabled

What does this mean? Does it mean he is saying that my chronic neck pain wasn't caused my work injury? I never suffered from chronic pain until the day of my injury. I believe I have an occupational disease. Any feedback?
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Unread 12-05-2012, 08:49 PM   #88
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The QME is saying your obvious damage is pre-existing not caused by a work injury. He is also saying the neck sprain is all the injury that occurred at work. Also you have reached what is known as max medical improvement, or medicine can not improve you anymore. As well as in his opinion that the injury could not have occurred by leaning over.

First keep in mind the QME works for the insurance company and has one goal. To manage cost, so of course he/she will try to minimize the case. Secondly you do not have to accept his opinion.

I also was injured at work 6/4/2012, my case is still open. I would recommend a few things. Get yourself a lawyer NOW. Every state has a time limit that you must consider when you have a work comp case. Learn as much as you can about the workers comp law in your state. Most libraries have a law library. Go there and ask for help, most librarians will be glad to help. DOCUMENT EVERYTHING including your own interactions with your lawyer.

Keep in mind there are different players involved. You, the employer, the work comp insurance company, lawyers and even the work comp commission. Each party has their own interest which may or may not be the same as your own at different times. One last thing and it is very important do not, DO NOT under any circumstance allow the nurse case manger from the insurance company to accompany you into the exam room. That person has no right or need to go into the exam room. They can and will get a report from every doctors appt you have.

If you have any questions private message me. I could go on for hours. Find yourself a GOOD doctor you trust don't let the work comp ins co pick one for you if you can do anything to stop that.
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Unread 01-10-2013, 07:06 PM   #89
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The PTP I am going to right now has said he wished he had a patient who worked as a former "adjuster" or the "UR". He said if they had horrible pain he would love to prescribe them aspirin or something ineffective, to pay them back for all the nasty games insurance companies played with his patients.


I know he is kidding because my PTP has the biggest heart of all, thanks for posting your story and sharing your experience with us.













Quote:
Originally Posted by lefthanded View Post
Jo55 said:




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. . . . .
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Unread 02-24-2013, 04:29 PM   #90
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I wanted to ask I have a workmans comp claim in Tennessee I have had rotator cuff surgery and carpal tunnel surgery it has been a year and a half on the rotator cuff and almost a year on the carpal tunnel doctor released me said nothing else could be done, got a second doctor and he told me that my shoulder never healed, my problem is that after doctor released me I quit my job because hours were cut and was not making the money I made before now I have to have surgery again will I still get the weekly benefits for being off if I had surgery have not settled my case yet.
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