November 17, 2019

Body Parts and Insurance Companies

authorized treating physician refusal to treatI recently had a long and somewhat heated conversation with an insurance adjuster about body parts.  Specifically, I wanted the adjuster to authorize medical treatment for my client’s neck and back , but the adjuster only wanted to authorize the treating physician to provide care for my client’s back.

As ridiculous as this may sound, this type of negotiation happens all the time in a workers compensation.  Though common sense would tell you that an employee who injures his low back falling from an 8 foot ladder might reasonably be expected to suffer neck injuries as well (such as when his head hits a concrete floor), insurance companies are very careful not to assume anything.

The problem in my case arose from my client’s first conversation with the posted panel doctor.  My client’s low back was in spasm and he was absolutely miserable, and he did not specifically mention any pain in his neck to the treating doctor.

I am thinking that my client had probably incurred a concussion and was not thinking straight in the first place so who knows what he told the company doctor.  By the time I was retained, almost two months had passed and now my client is receiving epidurals for his lower back – although he may need surgery soon – but no treatment at all for his neck.

When my client goes to the workers’ comp. doctor and tries to talk about his neck pain, the doctor tells him that the insurance adjuster has not authorized treatment for the neck so the doctor will not treat the neck.

Imaging a doctor’s appointment where the physician tells you “I’m sorry you’re in pain but I am not allowed to treat that part of your body!” [Read more…]

Can Insurance Company Deny Treatment for Medication Side Effects?

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.