Recently I had to handle a situation for a client when the workers’ compensation insurance company denied treatment for migraine headaches caused by medication given to my client by an authorized physician.
In this case, my client hurt his back badly about a year previously when he was lifting HVAC equipment. For several months, the insurance company fought us in our attempt to get proper medical treatment but eventually I was able to get him to a good doctor who scheduled him for surgery to repair a large herniated disc in his lumbar spine.
Post surgery, my client developed complications when fluid began to build up in the spinal canal. The surgeon prescribed a strong medication to help drain the fluid and prevent an infection. Unfortunately this strong medication resulted in migraine headaches.
Although the migraine headaches were new, the law in Georgia is clear that medical treatment and medications necessary to treat a complication from a compensable injury is also compensable and must be paid for by the insurance company. And, in fact, the insurance adjustor originally assigned this case, authorized my client’s pharmacy to dispense his migraine medication
Several weeks into the treatment regimen, a new adjustor was assigned to this claim. The new adjustor decided that the migraine headaches were not related to the work injury and she canceled the pharmacy authorization. Suddenly, my client was left without medication to treat his frequent and painful migraine headaches.
As you might imagine, this development left my client in a great deal of pain. I immediately got on the phone with the adjustor but she would not change her position. I then wrote the treating doctor to request a statement from him that “connected the dots” and related the migraine headaches to the original work injury. I also got on the phone to the defense attorney representing the employer/insurer to demand that my client’s prescription be approved. It took about 5 phone calls until I finally got the defense attorney to call me back – he acknowledged that our position was correct and he was able to convince the adjustor to start the medication authorization again.
This type of arbitrary action by workers’ comp insurance adjustors is all too common. Adjustors come and go and a reasonable, knowledgeable insurance claims person can be replaced by someone new who is inexperienced, stubborn or even vindictive. As a claimant’s lawyer, I make every effort to stay on top of problems like the one my client experienced and to take whatever steps are necessary to solve these problems.
A front page story in the Sunday, May 24, 2009 edition of the Atlanta Journal-Constitution details the struggle of five catastrophically injured Atlanta police officers to obtain needed medical help from the City of Atlanta’s workers’ compensation office. Each of these police officers was injured in the line of duty – with injuries ranging from brain damage to paralysis arising from gunshot wounds to the spinal cord.
Like many city and county governments, the City of Atlanta “self-insures” against workers’ compensation claims, meaning that weekly wage benefits and funds for medical treatment come directly out of the City’s budget. The City does use a private claim’s administration service called NovaPro Risk Solutions out of San Diego.
The City is not denying responsibility for paying wage or medical claims, but it has been refusing to pay for various medical procedures and medical devices.
In one instance a police officer who had been rendered a parapalegic from a gunshot wound needed surgery on his Achilles tendon because his feet kept slipping off his wheelchair footrests. More on Injured Atlanta Cops Fight Workers Comp System
If you are injured on the job and you are a covered worker under the workers’ compensation law, your employer is required to provide you with medical care. However, as you may suspect, what you consider as reasonable and necessary care may not be the same thing as what your employer and its insurer want to provide.
The posted panel of physicians is the starting point for your claim for medical treatment. Under Georgia’s workers compensation law, employers are required to post a list or “panel” of doctors in a reasonably accessible place for employees to see. A valid panel should have at least 6 indpendent medical providers on it and at least one of these doctors should be an orthopedist.
If your employer has a posted panel, you may select a doctor and schedule an appointment, with the cost borne by the ermployer/insurer. Often, your employer will try to direct you to a particular doctor or clinic with whom the employer has an on-going relationship. Under Georgia law, you as the injured worker have the right to select from any of the doctors on the panel. You can do yourself a real favor by avoiding doctors who may not have your best interest at heart – Ginsberg Law’s extensive experience with physicians throughout the State can be a huge benefit to you if you become our client.
If you choose to select a doctor on the panel that is different from the doctor that your supervisor is “suggesting,” you would be wise to ask the doctor’s office to verify that the workers’ compensation insurer has agreed to pay for the appointment. Some employers honestly do not understand that employees have the right to choose a physician, and sometimes employers and insurers will intentionally playing games with the payment of medical providers for unrepresented claimants even if those providers are authorized.
If there is no posted panel of doctors, or if there is a panel that is not accessible, or if you have never been given any explanation of how the panel works, Georgia law can provide you the right to select your own doctor. As you might imagine, employers and their insurers will do everything in their power to retain control of the course of your medical treatment. You may hear things like “that doctor is not authorized,” or “that doctor is not on our panel,” or “that doctor is not in our network.” Be aware that there have been dozens of litigated cases in Georgia relating to the posted panel, and factors that either validate or invalidate the panel. Part of our job as your attorney is to identify whether the posted panel issue is something to pursue or not.
To illustrate the importance of asserting your rights under workers compensation law, I would like to relate to you the story of a recent client of mine who suffered permanent nerve damage in his spine because of delays caused by the insurance company. As any reputable doctor will tell you, time is of the essence if you have a serious injury. If you have a serious injury to your back, neck, arm, knee, foot, head or hand a delay in diagnosis can result in permanent injury and inability to return to work.
Our case involved a situation where a client hired us after enduring almost a year of frustrating delays in medical care. The client had a significant back injury after falling off the back of a truck. He hit the ground and had sharp, shooting pains in his back and radiating down his leg, with numbness in his toes. He was ordered by his employer to see the clinic down the road from his job. For several months, he stayed under the care of this clinic – taking medication and undergoing therapy that did not help, and actually made him worse.
When this injured worker (not yet represented by our firm) asked for a referral to a specialist he was ignored and offered more therapy. The clinic doctors released him to “light duty,” which he tried to do with very limited success. Finally, after many months the clinic doctor ordered an MRI scan, which revealed herniated discs at 2 levels impinging on a nerve in the spine.
Again, the injured worker asked for a referral to a spine specialist and after another full month of delay, he finally got the referral. The specialist confirmed the diagnosis of disc and nerve injury and ultimately the injured worker (now our client) underwent a fusion of his spine. Unfortunately, the surgery did not relieve his pain, because our client had incurred permanent nerve damage due to the delay in care.
One of the issues that I sometimes face arises from my client’s initial report of his injury. When you are hurt on the job, you can help your case greatly by thoroughly and accurately reporting your injury.
Don’t just talk about the one injury that is hurting you right now. Instead, take an “inventory” of every part of your body that was involved. Don’t exaggerate, but don’t minimize problems either. For example, if you fell off a ladder, you might have immediate back pain. But, you might also have:
- concussion
- headaches from the hard landing or from hitting your head
- neck pain from sudden impact
- foot problems from landing on your foot ackwardly
- knee problems from landing on or twisting your knee
- hand problems from falling hard on your hands
Your employer may send you to a doctor. When you meet with the doctor, you want to begin creating an accurate paper trail. Report each and every body part that is affected, even if the doctor does not seem interested. Most doctors ask you to fill out an intake form – that form will become part of your case record. Use it to identify all problems.
If you fail to list all problems at the outset, the insurance company may use this gap to deny coverage and to limit treatment. If the insurance company identifies your case as a low back/hip case, they may not authorize your doctor to treat your knees or feet. You could literally find yourself being treated for one part of your leg, but not another part because the doctor is specifically not authorized to treat that other part.
It may sound crazy to you that your doctor will only treat part of your problems, but this is a common situation in workers compensation. The insurance companies put very specific limits on what they will pay the doctors to treat.
Now, what happens if you did not give your supervisor or your initial treating doctor an accurate description of your injury? It may not be too late. You may still be able to update your report of your injury and preserve your rights. I would advise you to speak to an attorney before trying to do this on your own.
Here is an example from one of my recent cases that demonstrates the importance of accurately reporting your injury.
My client was a carpenter who was carrying a 2×4 board on his left shoulder. His right hand was in his apron He fell down and landed on his left shoulder, leaving him in severe pain. The employer sent him to a local emergency room where he complained about his left shoulder. An MRI was done, showing a torn left rotator cuff that required surgery.
Following surgery and physical therapy, my client remained in severe pain. At this point, the injured carpenter called me. My first question – are you having headaches? I asked this because I know that headaches are a common symptom of cervical (neck) disc problems. I used the “employee’s second opinion” to have my client seen by an orthopedist who specializes in neck injuries. Sure enough, my client had a herniated disc in his cervical spine.
This cervical spine issue necessitated additional surgery and rehabilitation. Because the injury was more severe than originally thought, this case had significantly more settlement value as well. My client did have any medical background and there is no reason for him to know about the anatomy of the neck and shoulder. I do have an understanding of this anatomy because I have represented dozens of claimants with similar issues. This is a case where I was able to use my experience and knowledge for the benefit of my client.
Filed under Back & neck injuries, Georgia Workers' Compensation, Medical benefits, Winning Strategies by 
