December 10, 2018

How to Combat Insurance Company Delay Tactics and Refusal to Authorize Medical Treatment

What can you do if your treating doctor wants to refer you to a specialist, or tries to order an MRI or CT scan, but the workers’ compensation insurance company refuses to authorize this needed treatment?
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Under Georgia workers’ compensation law, if you are receiving care from a “authorized treating physician” and that authorized physician refers you to a specialist, the referred doctor is supposed to be authorized automatically.

Similarly, if an authorized treating physician writes an order for an MRI, CT or other diagnostic test, that test should also be authorized.

What we are finding, however, is that when the referred doctor or the medical testing center calls the insurance company to verify that they will be paid, the insurance adjustor may say “no.” And of course, if a medical provider or testing center does not have a source of payment, they will not provide treatment to you. [Read more…]

“Independent” Medical Exams Scheduled by the Insurance Company are Rarely Legitimate

Funny Doctor breaks the bad newsA very common tactic used by workers’compensation insurance companies to cut off your benefits involves the use of something called an “independent medical exam” or IME.  As you might guess, in my experience these medical evaluations are rarely independent and they often serve no purpose other than medical support for termination of benefits.

Fortunately, most of the State Board judges that consider workers’ comp issues understand how the IME game works, and they look at these results with a very critical eye, but insurance adjusters continue to use this practice as a matter of course.

When I get an IME notice, the first thing I will look for is the name of the examining doctor.  There are a number of physicians out there who work extensively for the insurance industry and in almost every file sent to one of these doctors, the resulting report will minimize the extent and nature of the work injury, question the relation of injury to the accident at work , and suggest that a full duty return to work is appropriate.

Because the insurance company has the right to send you out for one of these biased IMEs, you have no choice but to go.  I can usually predict what the forthcoming report will say and that the insurance company is planning to try to cut you off, so I gear up to request a hearing challenging the proposed cut off.

The file will end up on the desk of a defense lawyer who I most likely know.  He or she and I will talk and acknowledge that the insurance IME was a waste of time and we will either start to discuss settlement, or try to agree on a more unbiased doctor to see you. [Read more…]

Seriously Injured Workers Likely to be Fired

Construction Worker Suffering Injury After Fall From Ladder

Many of the folks I speak with about work injury claims are, quite reasonably, concerned about their jobs.  Steady, well-paying jobs are hard to find and reporting an on-the-job injury could have negative consequences for your employment.

If you experience a relatively minor injury, you should not have much of a problem – minor muscle strains or bruises usually respond to ice and a day or two of rest, and then you can return to work without any issues.  In most of these cases, the posted panel doc’s treatment will be sufficient.  Our experience has been that employers recognize that bumps and bruises are part of almost any job and your employment will not be at risk if you access the posted panel doctor and the workers’ compensation system.

Problems often occur when your injury is more than a minor strain. Or perhaps you have had a series of minor and not so minor bumps and bruises that have resulted in several visits to the workers’ compensation clinic and more than a few days of missed work.  In cases where your employer decides that you are injury prone or that your minor injury really isn’t so minor, your job may be in jeopardy. [Read more…]

Why Your First Doctor’s Appointment Following Your Accident is so Important

doctor visit after work accidentMost of us have seen police dramas on TV where the arresting officer tells the suspect that “anything you say can and will be used against you.” In your Georgia workers’ compensation claim not only do you have to worry about what you say, but you also have to worry about what you do not say.

In my practice, I often have to deal with the situation where my client does not discuss with his doctor all of the physical problems that arise from the accident.

  • Example: you fall from a ladder and land on your tailbone but you do not mention to the doctor that your neck is sore as well.
  • Example: you strain your lower back lifting a heavy box but fail to mention to the doctor that your wrist is swollen and sore and that your thumb is numb where the box fell on it

If you do not provide a complete list of your medical problems to the first doctor who sees you, later on you may find that the insurance company will refuse to authorize treatment for that omitted body part.

This results in a situation where later on in the case, for example, the insurance company notifies the doctor that they will pay for treatment of your lower back but not your neck, wrists or hands. You can find yourself meeting with a doctor who will literally refuse to treat you for the unapproved body part even if you are in extreme pain and likely to suffer permanent nerve injury if you do not get treatment. [Read more…]

How Insurance Companies Try to Cut You Off

aggressive insurance companyYou might think that if your employer is paying weekly benefits and has paid for medical care, you are not likely to have any significant disputes in your work injury case. As the case I am about to discuss shows, however, challenges from the insurance company may be right around the corner.

The case I want to highlight is not one of my cases. The decision in this case is part of the public record in that it is published on the web site of the Georgia State Board of Workers’ Compensation. I bring this case to your attention for several reasons:

  • first, I want you to see how a State Board judge analyzes evidence
  • second, there are certain elements of this case that are not discussed in the decision, but we can assume they are there because the insurance company did not raise the issue and the judge did not mention the issue. We’ll read between the lines to reveal these issues.
  • third, this is a case that shows how insurance companies operate to cut off the benefits of a deserving claimant and to force a below market settlement.

The case I am discussing was decided in 2013 in south Georgia. Because State Board files are confidential, neither the name of the claimant nor the name of the employer is disclosed.  Here is a link to the written decision.

The employee is a female who worked as the manager of a restaurant. In December, 2006 the employee hurt herself and developed neck pain which radiated into both hands and lower back pain that radiated into both legs. The employer accepted the claim and began paying her TTD (weekly wage) benefits. The employer also paid for medical care that include surgery on her cervical spine and surgery on her lumbar spine. [Read more…]

What is a Malingerer?

malingeringCertain terms that can be found in medical reports carry significant meaning.  If you see the term “malingerer” applied to you, this could be a significant problem for your workers’ compensation claim.

In a work injury claim setting a malingerer may be defined as one who fabricates or exaggerates the symptoms of physical or mental disorders for the purpose of avoiding work, obtaining drugs, remaining on weekly benefits, or increasing settlement value 1.  In other words, a malingerer is someone who claims that he/she cannot return to work despite the absence of medical evidence of a continuing disability.

Unfortunately in the adversarial world of workers’ compensation within the state of Georgia, accusations of malingering are tossed about with little to back up these claims.  However, if the judge in your case starts to accept this accusation it can leave you exposed to unfavorable rulings regarding termination of benefits, changes in treating physicians and disability ratings. [Read more…]

  1. Wikipedia defines malingering as fabricating or exaggerating the symptoms of mental or physical disorders for a variety of “secondary gain” motives

2013 Changes to Georgia’s Workers’ Comp. Laws

Georgia state legislatureEvery year the Georgia legislature considers a variety of proposed laws which may impact workers’ compensation.  This year, several bills passed the Georgia House and Senate and were signed by Governor Deal:

TTD maximum increases to $525 per week.  If you were injured on July 1, 2013 or after, your maximum temporary total disability payment amount increases from $500 per week to $525 per week.  The formula for calculating TTD benefits remains the same – you are entitled to 2/3 of your average weekly wage with a maximum benefit payment which is now $525 per week.

Mileage payments must be made faster.  When we submit documentation to recover mileage reimbursement (for travel to and from the doctor, a deposition or other approved reason), the insurance company must reimburse you within 15 days of submission date.  Previously they could wait up to 30 days to send the reimbursement.  If the mileage check is late, then you will be owed a penalty.

WC-240 return to work procedure changed.  If you attempt to return to work under a WC-240 or not, you must attempt to work for at least 8 hours or one shift for that attempt to be considered reasonable 1.  I continue to encourage my clients to make good faith work attempts.  Under the law if you cannot work for more than 15 days under the work attempt your TTD benefits must be reinstated.

Medical care now limited to 400 weeks.  As of July 1, 2013 injuries, the insurance company is obligated to pay for medical care up to 400 weeks (which is more than 7 years). Only if your case is deemed catastrophic will the 400 week medical benefit cap not apply 2.

  1. I strongly suggest that you not return to work without a WC-240 form.  The WC-240 is completed by your doctor and sets out your work activity limitations.  Read more about the WC-240 procedure here
  2. I have long argued that timing is one of the most important factors in maximizing your settlement.  This change – limiting the insurance company’s obligation to pay for medical treatment makes it even more crucial that we understand and calculate the insurance company’s possible exposure properly.  I discuss this timing issue more in this video