October 23, 2019

Can my Spouse Get Paid by the Insurance Company for Helping Me Recover at Home from my Injury?

workers comp reimbursementMany of my clients are surprised to learn that their husband, wife or significant other can ask for payment for “attendant care” of an injured worker at home.   Why?  Often my seriously injured clients cannot take care of basic necessities such as:

  • 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? [Read more…]

What to do About Substandard Medical Care in Your Workers’ Compensation Case

industrial clinic doctorIf you have never been involved in the Georgia workers’ compensation system before, you may be shocked and disappointed to learn that some of the physicians you meet seem to have an agenda other than your health and best interest. The Georgia workers’ compensation statute has created an environment where insurance companies have a financial interest to find and use doctors who downplay the seriousness of your injuries and who intentionally avoid referring you for necessary, but expensive care.  The net result of this system can mean delay and unnecessary suffering for you.

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. [Read more…]

Company Doctor Uses X-Rays Instead of MRI and Misses Herniated Disc

MRI ScanOften, when a worker injures his back on the job, the human resources manager will take down a claim and refer the worker to an industrial clinic for evaluation and treatment. All too often, the industrial clinic or other posted panel doctor will take X-rays, perform some basic neurological tests, then release the worker back to full duty work after a day or two of rest.

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. [Read more…]

The Nurse Case Manager – Who is She and Does She Belong on Your Case

[mc id=”175″ type=”audio”]Jodi discusses the role of the nurse case manager and when it makes sense to terminate her involvement[/mc]One of the lesser known players used by Georgia workers’ comp insurers is the nurse case manager. In the past, insurers could assign nurse case managers to every claim. Now, claimants and their lawyers can terminate the involvement of nurse case managers, except in the instance of catastrophic injury cases. Who is the nurse case manager and what does she do? In this short audio report, I explain how insurance companies sometimes use nurse case managers to try and influence treating doctors and I discuss a recent case in which I pulled the plug on a nurse case manager’s involvement.

Case Study: Workers Compensation for Severe Ankle and Foot Injuries

Welcome to the 7th installment of my summer long series on Georgia Workers’ comp case studies. In the following case study, I discuss a recent workers compensation case involving a severe ankle and foot injury.

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.

What is a Workers’ Comp Managed Care Organization?

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).