The problem, of course, is that delays in needed tests, or delays in needed treatment can result in permanent injury to you.  Further, if a panel doctor returns you to work and you are unable to perform your duties, you are likely to be fired putting you in a difficult financial situation and psychologically deterring you from pursuing your rightful benefits.

In this video I discuss a case where the authorized doctor flat out ignored his own physical therapist’s conclusions about my client’s very limited use of her arms, and issued a full duty return to work.  I won’t let the insurer get away with this, of course, but I wanted you to see how broken the workers’ compensation medical system has become.  I’d be willing to bet that this doctor knows that he was not living up to his oath to offer full and complete treatment to his patients, but his interest in making money and seeing those referrals seems to override his conscience.

In 1990, the Georgia legislature gave injured workers an important new right, the “claimant’s IME (independent medical exam).  Under this law, an injured worker can request an independent medical examination with a doctor of his choosing, paid for by the employer’s insurance company.

When properly used as part of a effective claim strategy, your claimant’s IME can be used to:

• refute the unfair and biased claim of industrial clinic doctors
• contest a premature return to work demand by the insurance adjuster
• support a request for a change in authorized treating physician
• support a reasonable settlement demand

However, as important and valuable as your claimant’s IME rights may be, this right is not open ended and it can be wasted if not used properly.

Specifically, I am referring to situations in which you may have injuries to multiple body parts and you are receiving treatment from several different doctors.   Recently, for example I represented a young man who had fallen almost 4 stories from a building, causing injury to his spine, a broken leg and a closed head injury.   In this case, I felt that the orthopedic doctor treating the leg and back injury, and the neurologist treating the closed head injury were not providing the level of treatment appropriate for the degree of injury.

Unfortunately, Georgia law does not provide for more than one claimant’s IME, even when multiple body parts are affected.   Therefore, I had to choose between an orthopedist and a neurologist for the claimant’s IME.  In this particular case I chose to request an orthopedic IME because I felt that my client had a more immediate need for back care and because I felt that I would have opportunity later to challenge the opinion of treating neurologist.

The points to remember about the claimant’s IME:

• be very careful about choosing to use this right – you will have one and only one opportunity to demand an insurer paid independent medical exam.  Knowing when to assert this right and knowing who to choose to perform this exam are crucial factors
• if you have injury to more than one body part, you only get one IME
• the insurance adjuster is not an appropriate resource to advise you about how and when to assert your IME rights

If you have questions about your claimant’s Independent Medical Exam rights, please do not hesitate to call me at 770-351-0801 begin_of_the_skype_highlighting 770-351-0801 end_of_the_skype_highlighting or email me.   Please also feel free to post a comment on my blog.

• bathing
• dressing
• meal preparation
• driving
• cleaning

Given that hospitals often release patients home as soon as possible, I see more and more instances where my clients recover mostly at home, with outpatient visits to rehab.

Under Georgia law (Georgia Code Section 34-9-200(a)), the employer/insurer must provide care that “shall be reasonably required and appear likely to effect a cure, give relief, or restore the employee to suitable employment.”   In the case of Medical Office Management v. Hardee, the Georgia Court of Appeals held that:

There is no express prohibition in the Workers’ Compensation Act against the recovery by an employee of attendant care services provided by a family member, including a spouse. Nor does the employer show that a family member cannot provide attendant home care under the Board’s rules and regulations…

The employer had argued against this “spousal reimbursement” on the grounds that the spouse was performing tasks he/she would do otherwise.   The Georgia Court of Appeals, as you can see, ruled otherwise, and permitted Ms. Hardee’s husband to collect a fee under the State Board fee schedule for attendant services.

What does this mean to you?

• First, do not expect your employer or its insurance company to offer to pay your spouse or significant other for attendant care.   Many insurance adjusters are not aware of the Hardee case and even some who are will tell you (incorrectly) that your spouse cannot collect.
• Second, it helps tremendously to have your authorized treating physician note the need for attendant care.  In my experience it sometimes is necessary to have the doctor write a letter specifically setting out the requirement for attendant care.
• Third, non-medical attendants like spouses or family members can get paid based on the State Board’s fee schedule, which sets a specific hourly rate and other limits
• Fourth, insurance companies will look for ways to avoid paying an injured workers’ spouse.  At a minimum, your spouse must have the physical and mental capacity to care for you.   You should seek legal counsel before submitting a request for spousal reimbursement.

If you would like to know more about spousal attendant care, please call me at 770-351-0801or send me an email.

I sometimes receive calls from injured workers who are receiving weekly wage benefits as well as medical care, who wonder why they should hire counsel if everything “seems to be working out okay.”  Sometimes they sense that something is not quite right but are wary of rocking the boat.

Know Your Doctor’s Reputation

I respond that one of the most valuable services I offer my clients has to do with my knowledge of and opinions about the medical providers that accept workers’ compensation referrals in Georgia.  After 20+ years of practice in this area of law, I have seen or know about the biases and quality of work offered by most of these doctors. Having worked as an insurance defense lawyer for several years at the beginning of my career, I can quickly identify an insurance company strategy to close out your case without addressing your medical needs or paying you a fair and necessary settlement.

Often the first indication you may have that something is not quite right may be a biased medical report.  Sometimes you sense the bias right away – when you visit an “industrial clinic” with an uncaring, assembly-line approach to medicine.  Sometimes the doctor you visit seems pleasant and caring, but you are stunned to read his report that minimizes your complaints, misstates your words, suggests that you are exaggerating your symptoms and releases you back to work far too soon.

Most of us are brought up to respect physicians and to defer to their opinions.  I am here to tell you that this type of blind deference is a major mistake in a workers’ compensation case.  You – or me as your representative – must advocate and advocate aggressively for your medical care.

Options if Your Workers’ Compensation Medical Care is Substandard

We have several options if we suspect that the posted panel doctor who is treating you is biased and unfair.

One Free Switch

First, under the Georgia workers’ comp. statute, we are allowed “one free switch” from one panel doctor to another.  Assuming that your employer’s posted panel is valid, you have the right to change doctors one time without explaining why.  In my experience, the quality of physicians on a posted panel can vary widely – sometimes switching from the industrial clinic doctor to a more independent physician can make a significant difference in your case.

Invalid Posted Panel

Second, we may discover that your employer’s posted panel is invalid.  I have written about the requirements for a valid posted panel of physicians elsewhere but if the panel if not valid, then you may have the right to seek company paid care with any doctor we choose, including quality health care providers that I know from other cases.

Along these same lines, Georgia law requires that posted panels contain the name of at least one orthopedist.  I regularly see panels of doctors that contain multiple names and thus appear to be valid, but do not contain the name of an orthopedist.  The absence of an orthopedist may very well invalidate the panel and give us control of your medical care.

Claimant’s IME

Third, under Georgia law, you as the injured employee can demand you “employee’s independent medical exam” (also known as the “claimant’s IME”).  This relatively recent change to the workers’ compensation law allows employees to choose a physician to conduct an evaluation that must be paid for by the employer/insurer.  While you will not get treatment at a claimant’s IME, the resulting report can be helpful evidence in your case and can support an effort to change the authorized treating physician.

Petition State Board for Change in Authorized Treating Physician

Finally, injured workers have the right to petition a judge at the Georgia State Board of Workers’ Compensation to order a change in the authorized treating physician.  In my practice I often find that I can negotiate a change in treating physician with the insurance adjuster.  If I see that your current doctor is not doing you any good or if I know that doctor to be biased in favor of the insurance company, then I will call the adjuster and arrange for a change.  If the adjuster will not work with me, then I request a hearing on the issue – although I rarely have to take such issues to court.

I hope you can see from this brief discussion that you do have many options if your current workers’ compensation authorized doctor is either not providing you with quality care or if that doctor is biased in favor of the insurance company.  I encourage you to tap into my knowledge and experience with workers’ compensation medical providers in Georgia.  Call me at 770-351-0801 or email me.  I look forward to hearing from you soon.

I often get these cases four to six weeks later when the injured worker finds himself unable to work because of severe back pain and limited mobility.   In some instances the injured worker faces pressure and even harassment from his employer due to his decreased productivity, and when I get the case, the employer/insurer may try to argue that any serious injury to the employee may have happened at home instead of at work.

Recently I represented a very nice young man in a back injury case that clearly demonstrates why X-rays are insufficient to evaluate back pain.

My client is a 31 year old man whose job involved installing and reinstalling fence posts.  Starting at 8 AM, my client, using a sledge hammer, loosened fence posts by breaking up their cement foundations, cleaned the post base, then reinstalle the post with fresh cement.  Beside using the sledge hammer, my client had to carry heavy buckets of cement and pour them in to holes in the ground.

By 2 PM that day, my client felt a “pop” in his back when he tried to lift the sledge hammer and he felt radiating pain in both legs.  He reported the injury to his supervisor, who referred him to an industrial clinic.  The clinic doctor took X-rays which described “mild disc space narrowing at L4-5″ but no other impairment.

The clinic doctor did put my client on “no work” status, where he remained for two months.  However, during that two months, the employer/insurer did not start his weekly wage benefits (although they did authorize on-going medical care at the industrial clinic).

After two months of suffering intense pain and no weekly wage benefits, my client called me and hired my firm.  I immediately contacted the adjuster and demanded that the employer/insurer commence weekly wage benefits – my client got a check for past due benefits plus a penalty payment arising from the employer’s late payment of those benefits.

Next, I contacted the adjuster to demand better medical care.  The adjuster and I agreed on a more neutral doctor and we agreed that an MRI was necessary to properly evaluate my client’s ongoing back pain.

As I expected, the MRI showed significant damage to my client’s lower back.   Specifically, the MRI revealed:

• a central disc herniation at L3-4 and L4-5 with narrowing of signal canal and mass effect on thecal sac;
• bilateral neural foraminal narrowing  at L4-5 and on the left at L5-S1
• disc dessication at L3-4 and L4-5

My client was subsequently scheduled for surgery and is now recuperating.  Click on the link to view the actual X-ray report and the MRI report:

1. First, the employer/insurer was not looking out for my client’s best interest.  They were satisfied with the somewhat irrelevant X-ray result and would have been happy if my client has just gone away.   MRIs and CT scans are a lot more expensive than X-rays but that is what should have been ordered in this case.
2. Second, even though the employer/insurer authorized industrial clinic treatment and pain medication, they did not start weekly wage benefits.  Why?  I have no idea.  My client was on a “no work” status from one of their doctors but they just did not pay weekly wage benefits.  Perhaps the adjuster messed up or perhaps they were hoping my client would never notice.
3. Third, you have to be your own advocate and/or hire an advocate like me to represent your interests.  My client has no formal medical training but he knew instinctively that something was seriously wrong with his back despite what the X-ray said.   X-rays are not designed to show soft tissue (nerve and/or disc material) damage.  Further, the longer a spinal nerve is compressed the more likely that the patient will suffer permanent damage.  Hopefully, my client will not experience any permanent damage, but I know that he suffered two weeks of unnecessary pain because the employer/insurer was looking for the least expensive option.

Severe ankle and foot injury Workers’ Compensation case

This case involved an ankle injury incurred by woman (Mrs. K) who worked in a warehouse environment.   While moving a bulky 250-pound steel panel, Mrs. K and her co-workers paused to rest after moving the steel panel only about 10 feet.   The panel became extremely unsteady and fell on her Mrs. K’s foot, snapping and breaking the ankle and foot.   Mrs. K was immediately rushed to her local hospital’s ER where she would undergo surgery to stabilize and immobilize the fracture.

After her surgery, Mrs. K was referred to a physician from the posted panel of physicians who saw her 3 days after her surgery.  Despite the severity of her fracture, the panel physician did not take X-rays to evaluate the union of the bones, nor did he conduct any nerve function tests to evaluate any possible loss of function.  Instead he left the cast on and prescribed pain medications.

After just over a week living in intense pain, Mrs. K.  found me through my web site and retained me to represent her.  After reviewing the medical record, it was obvious to me that Mrs. K needed additional surgery and she needed a surgical consult quickly.  I contacted the insurance adjuster and persuaded the adjuster to refer my client to a foot and ankle specialist.   The foot and ankle specialist diagnosed the foot fracture as a “displaced” fracture, meaning that another surgery was needed and that plates and screws would have to be used to stabilize the foot.  This, of course, means that a third surgery likely would be necessary to fully or partially remove this hardware.

Because of the delay in getting Mrs.  K to the appropriate physician, she suffered complications – ecchymosis (skin discoloration) up the leg to her knee and neuropraxia (loss of nerve function) throughout her foot.    In my opinion, these complications would not have occurred, or would have been less severe had the 2nd surgery been performed earlier than it was.

Mrs. K is still recovering from surgery.   Her job had required her to stand, squat, lift and stand, and she cannot perform the duties of her past job.  Rehabilitation is proceeding slowly and I estimate that she will be out of work for at least 6 to 8 months.

Mrs. K has not yet had her second surgery and it is not clear to me how invasive that second surgery will be.   I expect that we will make a settlement demand either before or after the second surgery.

In my view, this is a case in which the insurance company’s delay and their reluctance to get Mrs. K to the right doctor quickly on what was clearly a surgical case will dramatically increase the settlement value of this case.  More importantly, I am of the opinion that my client’s health was compromised by the insurer’s delay, not to mention the unnecessary suffering she experienced.   I further suspect that had she waited 3 or 4 weeks before hiring me, a second surgery would not have been scheduled as the initial panel doctor seemed oblivious to the severity of this injury.

This case illustrates the importance of recognizing that medical treatment under workers’ compensation can be substandard and inadequate.  The panel doctor’s motivation and loyalty was not to his patient, but to the insurance company.  Ironically, the panel doctor’s failure to act will end up costing the insurance company more money.

In the state of Georgia, you are entitled to receive worker’s comp benefits if you are injured on the job and the following criteria are met:

• You are a regular employee – whether full-time or part-time
• Your employer has employed 3 or more individuals
• You are not an Independent Contractor (IC)

Additionally, you cannot be employed in certain industries or occupations such as maritime or railroad, as they provide their own types of benefits insurance. Typically, there are 3 primary forms of benefits:

• PPD or Permanent Partial Disability
• TPD or Total Partial Disability
• TTD or Temporary Total Disability

In addition to the above benefits, your employer is responsible for providing you with the medical care and treatment you need at their expense. Typically, your employer provides you with medical benefits by selecting certain providers of medical care for the injured employee. The listing of medical providers is oftentimes referred to as Managed Care Organizations or MCO’s.

What is a Managed Care Organization?

Managed care is defined as a variety of methods or techniques which are intended for the reduction of costs associated with providing health care and medical benefits. Additionally, the other intention of managed care is to improve the quality of that health and medical care for those organizations that use these methods and techniques. These organizations are referred to as MCO’s or Managed Care Organizations.

The terminology managed care is also used to describe systems for delivering and/or financing health and medical care to enrolees who are organized around certain managed care concepts and techniques. A managed care organization refers to any entity which manages the use of health and medical care as well as the associated costs specific to worker’s compensation claims.

Some of the more common MCO’s

There are several groups of organizations currently providing managed care for employees who have sustained on-the-job injuries. Each of them operate using business models that are slightly different from one another. Some of these organizations are comprised of a mixture of hospitals, physicians, and other health care providers whereas others are comprised exclusively of physicians. The most common MCO’s are:

• Group practice without walls
• Independent practice associations
• Management services organizations
• Physician practice management companies

Additionally, there are several other network-based MCO’s such as HMO’s (Health Maintenance Organizations, IPA’s (Independent Practice Associations), and PPO’s (Preferred Provider Organizations).