Rating an Injury Known to Require Future Surgeries

[caliquestions]

Hello,

I was wondering about how an injury that positively requires future surgeries might affect the disability rating.

I had a hip replacement surgery from my injury, and because I am younger(mid 30's) than the typical recipient of this joyful device, I am expected to have a replacement surgery 12-15 years down the road.

Because no matter how well I am doing down the road with another job, I am going to have to revisit the horror of this surgery. Will the ratings folks take this into consideration?

Thanks again

[.SH]

No.
California uses the AMA guides to rating disability. The guide does not compute a current rating contigent on medical treatment in the future. There are other factors that determine how serious the disability is (range of motion, atrophy, diagnosis, etc.)
Medical benefits are a separate catagory and are also not restricted or tied to a particular rating - both operate independently.

[twomoons]

sh
thanks for that reply . i did not know that my doc has said i need at least one more cervicle fusion on c 4 to c6 .in fact he would not give me a p&s status because i need another surgery. but my lawyer wants a rating so he can go to a msc .
thanks for the advice

[caliquestions]

Thanks for the reply!

[BvIA]

''my lawyer wants a rating so he can go to a msc .''
Tell your lawyer to hang it up... do as your PTP tells you to do.. your attorney is looking to settle your case to get his fee... after that you will be in FM mode...


''I was wondering about how an injury that positively requires future surgeries might affect the disability rating.''

This will not affect your PD/WPI rating. What it will do is make a difference in the amount of your future medical award, IF you choose to settle your case by a C&R. BUT, do not look for the IC to make an offer any where near what another surgery will cost. The IC would rather take the bet you will not have the surgery, or you will die of other cauese before you need it. There is no way you can make an estimate on what a hip replacement will cost 10 or 12 years from now.

[caliquestions]

Hi,

Just in case you were wondering. The hip replacement itemized bill I recieved from my insurance was over $250,000. Each night in ICU was 14k, and I spent 6 days there, and another 5 days in a regular room. That was just the surgery hospital. After that I was transfered to a rehab hospital where I spent another 7 days learning to use a walker and get out of bed, etc...

So all said and done, this might be over 300k.

If I start another job, get health benefits, they cannot deny me for a previous condition. So if I start work, get medical benefits, 12 years later I need a hip replacement, there should be no problem . Maybe the laws are different in other states, but here in California when you get a job with medical (almost every employer), they can not say they will not cover a pre-existing condition. Maybe if I choose to buy my own health insurance, but who can afford that?

[.SH]

you better confirm that with the health carrier about work comp injuries -- there are an awful lot of denials by health providers over treatment for work injuries.

[caliquestions]

OH.

I have never filed WC before, I never thought about that.

Thanks again.

[BvIA]

If you were to return to work and obtain private pay health coverage through your ER, or on your own, the new IC would not be liable for additional treatment to your work injury you are dealing with now.
Where there is a 3rd party liability, a new carrier can refuse treatment.

IF you were to settle this case by a C&R, which isn't likely, and you allowed another carrier to pay/provide treatment it could be considered fraud...you would already have been compensated for treatment to this injury...you cannot have coverage from 2 carriers at the same time, it would be 'double dipping'...

While it is true there are circumstances where the IC cannot exclude pre exsisting conditions... you already have coverage for this injury.

[Jackie]

I hope this will help you. This is what I know to be true in regards to future health coverage and your pre-existing WC injury. This applies ONLY to group plans offered by your employer and DOES NOT apply to any individual health plan you may purchase for yourself. As a rule, most employer group policy health plans are a "blanket" coverage and do not require an application or disclosure of any pre-existing health condition. Regarding health insurance through your new employer, By law, they cannot deny you future coverage due to your previous WC injury PROVIDED:

You had no need for immediate medical treatment when the case was settled,
AND
You had no knowledge of need for immediate medical treatment or knowledge of need for treatment in the very near future, at the time of settlement.
AND
Your claim was settled with no future medical provisions and there is no other recourse regarding collection of monies from other parties.

BvIA , sorry to step on you toes, but this is not "double dipping". If the WC case is closed, that leaves only one current provider,- the health insurance carrier. Also, when someone reaches settlement and is awarded compensation, they are compensated for the INJURY not for the cost of previous treatment, which is paid directly to the healthcare provider. WC is responsible for all medical costs arising from your work injury. This is in no way considered to be a form of compensation. It is in effect a form of health insurance coverage which provides payment for medical claims incurred directly by your work injury. Those payments are benefits afforded you as a qualified injured worker and are not even remotely related to the award. In terms of compensation from future medical award, we all know it pays pennies on the dollar. Hopefully it will cover future co-pays, although it probably won't.
There's not an insurance provider out there that could ever reasonably believe that a future medical award would even begin to cover any of the future medical expenses. They don't expect you to.

FYI * Employer Group Plans:

Choose your plan CAREFULLY!!, with PREFFERENCE for a PPO plan and remember if imformation on your pre-existing condition is not required, do not disclose your injury. When receiving future treatment and your WC case is closed, it is no longer necessary for billing reasons to list it as a WC injury, it is just an injury.

If given the choice, DO NOT choose an HMO for your group coverage. They are notorious for denying medical treatment anyway. Some may try to exclude your pre-existing injury until you have reached the end of a two year waiting period without any type of treatment for that injury. I don't believe this is legal, but some will try it anyway and by the time you win this battle, two years will have passed anyway.

FYI *Private Plans

Private health plans require full disclosure of existing health conditions and it is fraudulent not to disclose that information in full. Private insurers can cancel your policy at any time if you have made a misleading or fraudulent statement on your application. In addition, you are liable for all medical claims they have paid as a result of your misleading or fraudulent statements and they may prosecute you in a court of law for insurance fraud.

You may still be able to get private insurance although it certainly is not optimal. Usually, if you have a mild pre-existing injury such as simple back strain, simple fracture etc. most private insurers will cover this after a two year waiting period, provided you do not receive ANY medical treatment for your injury during that time. For more serious injuries or conditions, they may offer you a health plan with exclusions for the pre-existing condition.

Also, although I have no idea how the recent WC "REFORMS" have changed the current standards regarding a future medical award, I do know that previously it was a "hefty chunk of change". It won't however, change your PD rating.

Hope this helped.