Welcome to the 2nd installment of my summer long series on Georgia Workers’ comp case studies. In the following case study, I discuss Reflex Sympathetic Dystrophy (RSD) and Workers’ Compensation.
What is Reflex Sympathetic Dystrophy?
CRPS or complex regional pain syndrome as it is technically known by is a progressively chronic disease that is characterized by changes, pain, and swelling of the skin. It is a disease which to date has no cure and has been divided into 2 categories (see below). Nerve lesions are often present after the injury has occurred.
CRPS Type I was originally called RSD or Reflex Sympathetic Dystrophy, and Type II was originally known as Causalgia. The key difference between the two types is that Type I does not typically result in nerve lesions whereas Type II displays significant nerve damage. Not only is there no cure for the disease, there is no apparent cause to this condition. Injury followed by surgery is typically a precipitating factor. However, there have been cases documented that show no injury actually occurred to cause CRPS or RSD.
Workers’ Compensation and RSD: The case of “Ms. F”
The case involving Ms. F, a Macy’s sales associate, is one in which she suffered an RSD injury as a result of a heavy sales sign falling from a display table and injuring her left ankle. Her pain was immediate and she was taken out of the store in a wheelchair. She was taken to the ER at a local area hospital where she was diagnosed with a contusion and laceration of the left ankle. Upon receiving her diagnosis, Ms. F was then taken to urgent care for further treatment. Unfortunately, her pain was not reduced.
Ms. F was then referred to an orthopedist (Dr. C) who treated her in conservative fashion. However, this did not diminish her pain levels either. Additionally, she was unable to walk. As a result of her inability to walk and her pain levels, Dr. C ordered an MRI which revealed the extent of the damage to her ankle. The metaphysic area of her distal femur had a small lesion apparent in the MRI. Dr. C determined that this was indicative of an RSD injury and he then referred Ms. F to Dr. L who performed NCS (Neurocardiogenic Syncope).
Dr. L determined that Ms. F has suffered a “2nd degree left peroneal motor nerve injury distal to the ankle.” In simple terms, my client had sustained permanent nerve damage due to the work injury. Her injury had already required extensive and costly treatment, and it would likely continue to do so.
To this date, she is under a new doctor’s care; Dr. L referred her to a RSD specialist. The client has been unable to work since the date of the incident, and it appears that she will be out of work indefinitely. Based on the above circumstances, our firm demanded “X” amount as a settlement for Ms. F’s case, and we successfully got our client the settlement she needed to cover the costs of ongoing medical care, lost income from not being able to work, rehabilitation costs, etc.
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I often explain to my clients that a major struggle in any workers’ compensation case relates to medical care. Georgia law gives employers the first opportunity to decide where an injured worker must go for treatment but this control is not complete:
- if your employer does not provide a valid “posted panel” of physicians you may be able to seek care with any physician and your employer and its insurer must pay for this care
- you can switch between one posted panel physician to another without prior permission
- you can request a change in authorized treating physician
- you can request a claimant’s IME
The claimant’s IME is a very interested feature of Georgia law. First enacted in 1990, Section 34-9-201(e) provides that an injured worker can demand an independent medical exam with a physician of his choice, paid for by the workers’ comp. insurance carrier. In my practice I use this “claimant’s IME” frequently to get a second opinion about questionable existing care or as evidence to support a request for permanent change in authorized treating physician.
Of course your right to a claimant’s IME under Georgia law is not absolute – I recently wrote an article about this topic on one of my web sites. Take a look if you are not happy with the quality of medical care you are receiving – and let me know what you think.
Case Study: Injured worker’s employer illegally discourages him from pursuing workers’ comp benefits
Throughout this summer, I plan on posting several Georgia workers’ compensation case studies. These case studies involve actual cases I have managed in recent years, and they often touch on many issues people may face when going through the workers’ compensation system in Georgia. All names of clients, employers and physicians will be changed so as to protect the privacy of my clients. Today, we will discuss the case of “Mr. B,” an injured worker whose employer tried to pull an illegal move and direct him to pursue an insurance claim with his own insurer rather than pursue workers’ comp benefits.
The Workers’ Compensation case of “Mr. B”
Mr. B was injured on the job when he lifted roughly 100 pounds of rubber materials. He injured his back as a result of the accident, and he also reported pain radiating down into his legs. He was referred to Dr. G for immediate conservative care, and soon after initial treatment, the client was referred by Dr. G to Dr. C for lumbar spine surgery. The goal if surgery was to repair a herniated disc and relieve his continual radiating leg pain. Once Mr. B successfully completed the rehab phase of his treatment, he returned to his place of work roughly 3 months after the surgery was performed.
Unfortunately, Mr. B was only able to work for 2 weeks; his back and leg pain flared up again, preventing him from working. Dr. C placed him on “off-work” status, and the client stayed out of work accordingly. According to medical records, both doctors G and C agreed that his injuries were work related, and both persisted in obtaining authorization from Workers’ Compensation.
However, a problem occurred in this case. The employer discouraged our client from pursuing workers’ comp benefits based on his job accident. Rather, the employer insisted that the employee take the issue to his own insurance carrier and file it as an LTD (Long Term Disability)/STD (Short Term Disability). This is highly illegal, especially since there was clear evidence that our client had been injured on the job. Even early paperwork from the employer indicated that this was a job injury. Therefore, according to Georgia workers’ comp law, out client was clearly entitled to workers’ comp benefits.
When we stepped in, we helped our client realize that he indeed needed to pursue his workers’ comp claim and then started looking at the specifics of his case so that we could prepare a settlement demand. We helped our client settle the case for a fair amount, and he now receives TTD benefits and will be aptly covered for any future medical costs.
The point here is that if your employer tries to discourage you from pursuing workers’ comp benefits and instead suggests that you pursue your own insurance claim, then you should realize that this is illegal and that you should probably speak with an attorney who can help you better understand your claim. A workers’ comp attorney’s job is to make sure you get the benefits you deserve and need, as well as to make sure your employer doesn’t pull any illegal moves.
Stay tuned for additional case studies!
Filed under Back & neck injuries, Case studies by
What is Worker’s Compensation?
Worker’s compensation, or more colloquially worker’s comp, refers to a type of insurance which provides certain benefits to employees that are injured on the job such as income due to lost wages and medical treatment. Additionally, the employee relinquishes their right to sue the employer for negligence once they file a worker’s compensation claim. Oftentimes, the trade-off between the assured, limited coverage versus the relinquishing of legal recourse is referred to as “the compensation bargain.”
What is covered and not covered?
While there are some differences between state worker’s compensation laws, the underlying intention and premise of worker’s comp benefits is the same. For instance, in the state of Georgia, any employer who employs three or more individuals, regardless of full-time or part-time status, must provide worker’s compensation insurance. They must also provide the injured employee, at their expense, proper medical care for the on-the-job injury.
Additionally, in cases involving the loss of a limb or the death of the employee is the case, worker’s compensation benefits are also provided. For instance, if you lose an arm or a leg and this causes you to take a lower paying job or position, you are entitled to benefits to cover the loss of wages. Similarly, if you die as a result of the industry, your spouse and children are entitled to benefits.
Other benefits that may be necessary
In addition to the above, not all of the benefits provided by Worker’s Compensation Insurance involve lost wages and medical care. Sometimes it is necessary to provide the injured employee with either rehabilitation benefits or vocational benefits. If this is the case, you will receive these benefits should there be an injury rehabilitation period involved, or if you need vocational training in order to perform a different job or have to take on a new position in the company where you were injured.
Worker’s comp rehab benefits apply to a variety of circumstances when they become necessary due to the on-the-job injury you have incurred. These include:
- Prosthesis and learning how to perform your job with the artificial limb
- Physical therapy required in order so that you can function and perform your job normally
- Speech therapy
- Vocational therapy (learning how to perform a different job)
If you need further information regarding any of the above or have any questions, please call contact us by visiting our website or sending us a comment using the form below.
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Who is entitled to worker’s compensation benefits?
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).
Filed under Medical Care by
What is an independent contractor?
Any business, corporation, or individual that provides products or services to a business entity and is specified contractually or by verbal agreement is referred to as an “independent contractor.” According to the IRS tax codes, they are not defined or recognized as an employee of that business or corporation. They typically work as they are required to and are usually subject to what is called the Law of Agency.
Additionally, independent contractors (hereinafter referred to as IC’s) are responsible for paying their own federal and state taxes; this is not the responsibility of the business, corporation, or individual who has contractually procured the IC’s products or services. Compensation is normally made on a freelance basis and the IC may be working through a limited company which they own themselves or via what is called an “umbrella company,” a company that acts as the agent for the IC.
Does worker’s comp cover the independent contractor?
Under the worker’s compensation laws of the state of Georgia, independent contractors are not covered for any injury sustained while performing their work. However, the definition of an independent contractor under state statutes has very specific guidelines in order to determine if the individual is an employee or an IC. Employers do not always use this definition correctly or properly. Additionally, the IRS’ guidelines regarding IC’s are not followed by worker’s compensation law.
For these reasons, this is a very problematic area. However, it is extremely ironic that an individual who has opted for being an independent contractor and who engage in dangerous or high risk occupations are not covered by Worker’s Compensation Insurance based on their independence or freedom from an employer. But the fact that employers would love to classify employees as independent contractor is what leads some to cheat and do exactly that so they are not responsible for worker’s comp benefits.
The bottom line is that if a business owner or corporate entity has 3 or more individuals working for them and they require a method, manner, time, and the type of work that the individuals are expected perform, they cannot classify the individual as an IC. Any business owner who employs 3 or more individuals is required to carry Worker’s Compensation Insurance. It is not surprising then that some employers try to “cheat the system” in order to avoid purchasing this type of coverage.
If you would like more information regarding the independent contractor/worker’s compensation issue, please feel free to contact us at our website. We will be happy to answer any questions you may have and provide you with additional information.
Filed under Employee vs. independent contractor, Georgia Workers' Compensation by
Workers’ Compensation Insurance can cover mental conditions. However, for this to happen, you really need to be able to link the mental condition to a specific event – such as a traumatic event experienced on the job or the development of a physical problem which then lead to your mental problem. Mental health issues are rarely compensable in and of themselves; linking them to physical events is key to receiving workers’ comp benefits based on psychiatric issues.
The argument would go something like this: At such and such time, you were injured on the job, at which point in time you begin exhibiting the signs of depression. The depression is clearly related to your job injury, and thus you should be eligible for Workers’ Compensation. Another example would be an individual having a heart attack due to the stress of their job, and in the aftermath developing an anxiety disorder which has debilitating consequences.
In any event, to get workers’ comp benefits, the primary condition or injury should really be physical in nature; however, mental conditions of the person would definitely be taken into consideration. Just know that for the most part, it must be proven that the mental condition was a direct result of a work environment that was not normal or a specific triggering event/injury.
Which leads to a last point – you will need evidence to show that this is the case. Naturally, something like a psychiatric evaluation would be required in order to determine whether a mental condition exists and whether it resulted directly from performing one’s job responsibilities.
Mental Health Issues and Workers’ Comp Case Study: The case of “Ms. D”
Ms. D experienced a head injury while on the job and was treated for it. However, she has been plagued with recurring headaches since the injury and treatment occurred. According to Dr. X, Ms. D suffers from continual headaches, and medical reports show that the headaches appear to be a direct result of the original injury and the medications taken as part of treatment.
In addition to the above, though, Ms. D is also anxious, depressed, and having difficulties sleeping. Consequently, she was fired from her 25-year job and hasn’t worked since. To deal with her mental health issues, she needs psychiatric care for depression, and relaxation techniques as prescribed by Doctors X and Y. She has been placed on “no work” status, and the net result of all of this will require that she receive TTD payments.
As her lawyer, I looked at all this information and was able to argue for a clear connection between the initial traumatic injury and the ongoing headaches and psychiatric issues. Treatment for both of these ongoing issues was pricey (we reviewed the costs and quotes for ongoing care), and we calculated a settlement amount for our client based on future medical care, follow-up appointments, future medications, and TTD requirements. Based on all the above, we demanded settlement of “X” amount on behalf of Ms. D’s and were able to successfully settle.
In conclusion, this was a case where we were able to get compensation based partially on mental health issues, but the key was clearly tying those issues to a physical event – in this case an on the job head injury.
Filed under Case studies, Depression by
