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  1. #1
    Join Date
    Apr 2007
    Posts
    52

    Default Refuse to take epidural injection

    I have alow back injury in 05,idid have surgery my surgery faild,aftermy surgeryfaild ,icant get any kind of treatement requested by my ptp

    some been denied formaly ,and some ignord by ic.

    we did go to court several time to get things done.my qustion .

    is if a refuse to take some of these treatement like epidural shot what canthe ic do for me. idont get any type of payment from the ic.


    2-can i sue tht ic for bad faith. if yes how


    thank y

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,017

    Default Re: refuse to take epidural injection

    As your DOI is 2005, your TTD has stopped due to the 104wk cap on the benefit.
    If the PTP's request for treatment has been denied by the UR process, the PTP can appeal the denial, but this must be done within the legal time frame..it is 20 days for an appeal of UR denials. Authorization of requested treatment is based on the ACOEM guidelines (or other EBM provided by your PTP)
    If you disagree with a UR denial, or other medical issue in your case, you can initiate the PQME process to resolve the dispute. On opinion by a PQME will trump that of the UR doctor. If you have an attorney you would use an AME to settle a dispute.
    A CA cannot deny a medical request, only approve or refer to UR for approval/modification/denial. There can also be ramifications because the CA ignored the request. If you don't have a response to a valid request for treatment by your PTP within 5 days of submitting the request it is presumed approved. You may also be entitled to penalties for a delay in providing benefits.

    You can refuse treatment any time you wish. But they can stop your benefits for doing so. Sometimes it may be necessary to try alternative treatments, like epidurals, before a more agressive/invasive prodecure is contemplated.
    If the treatment for your injury has been exhausted, or you are not a candidate for something like surgery, your PTP should/could write a request for a comprehensive evaluation at a recongized pain management facility. This is provided for in the guidelines per ACOEM/new guides for pain management. It involves much more than simply Rx pain medication.

    ''2-can i sue tht ic for bad faith. if yes how''

    No...your recourse for a work related injury is claiming benefits though your ER/IC, which you have done. There is no "bad faith" in WC. You can file for hearings with the WCAB, which you are familiar with, and let a judge make the determination in your dispute.

  3. #3
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: Refuse to take epidural injection

    wrong.

    work comp carriers are subject to bad faith suits like any other carrier.
    there are some exceptions to the "exclusive remedy" provisions of work comp law and bad faith is one of them.
    The most difficult step in filing a bad faith suit is getting an attorney to take the case.
    You need a lawyer experienced in these type cases. there are not many. you should be able to get help finding someone to discuss potential representation from your state bar
    http://calbar.ca.gov/state/calbar/ca...=11584&id=9185

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,017

    Default Re: Refuse to take epidural injection

    An IW would not have a cause of action to "bad faith" against a WC IC. While there may be 'bad faith' in WC, it would only be between the ER who purchased the policy to provide the benefits to the IW, and the IC providing the coverage.
    The IW has no contract with the IC providing the benefits....therefore there is NO ''bad faith'' between an IW and a IC providing the WC coverage.
    Don't waste your time trying to find an attorney who will consider taking such a case...
    The IW's recourse/entitlement is to claim benefits for the work related injury as provided by the state laws governing the provision of said benefits.
    So, I'll rephrase the statement... "There is no 'bad faith' on the part of the IW in WC"... I apologize if that was confusing.

  5. #5
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: Refuse to take epidural injection

    wrong.
    you can't explain your wrong answer away, steve. it is still wrong.

    the carriers duty to deal in good faith which is the basis for "bad faith" not only governs the relationship between a policyholder and the carrier but also between benefit provider and the recipient.
    In most cases they are one and the same.
    In workers comp the benefit recipient is the empoyer's worker.
    In that situation an employee or injured worker also has a legal right to "good faith and fair dealing" and in the absence of that they can file a "bad faith" action.
    Please check your information before trying to help. I know it's well intentioned but correcting good information by offering bad is not helpful.

    .... being stubbord about it is worse.
    Last edited by .SH; 11-07-2007 at 11:52 AM.

  6. #6
    Join Date
    Feb 2007
    Posts
    550

    Default Re: Refuse to take epidural injection

    You are Both RIGHT.

    SH, what you have to realize is that there may be a Cause of Action that ostensibly exists for Bad Faith against an Ins Co. HOWEVER, IN REALITY, the bar is so HIGh, and the cases so far and few between, that the odds of prevailing are slim and none.

    The one case that was seminal (and the name escapes me) involved a man who ended up in a wheelchair due to the action, or inaction of the Ins Co. I tell IW's, and I recently stated this on a post here, UNLESS YOU ARE IN YOUR WHEELCHAIR, TYPING YOUR POST WITH A STICK IN YOUR MOUTH, because of the actions of an IC, you are SHIT OUT OF LUCK!!!! I have a file of these cases, somewhere. Maybe i will do a Lexis search, later. If Bob Bollinger is around, perhaps he can contribute, also.

    WHat an IW believes is "Bad Faith", and what the Ins Codes and case law define as "Bad faith" are day and night, SH. Here, the IW was denied an epidural, and wants to know about Bad Faith. NO FREAKING ATTY IN THE WORLD WOULD TALK TO THIS PERSON about a bad faith action on these facts. Bad Faith in the WC realm must go wayyyyy beyond the pale.

    I think it is great that you give advice, SH. You are an invaluable assistant to the IW's. However, I think sometimes you give them false hope, and let them believe than can sue their atty and prevail, and they can file bad faith actions, and prevail.

    I see and hear these things everyday. And, I have yet to see ONE case go forward.


    LA

  7. #7
    Join Date
    Oct 2007
    Posts
    84

    Default Re: Refuse to take epidural injection

    Just to take it in another direction, Can IW refused the epidural, if previously had one, and it caused bad reaction, docuemented. My nuero ordered, micro disectom, and UR denied, stateing I needed to go thru conservative therapy first, ie; epidural injection, which has in the past sent me str8t to to Emergancy room in extreme pain. I will not do it agiain. I had been doing conservative therapy , on a home program.

  8. #8
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,017

    Default Re: Refuse to take epidural injection

    1bigouch,
    As you suffered a unacceptable reaction to the previous attempt at 'conversative' treatment, the epidural, it is up to your PTP to provide the explanation to the UR doctor. If necessary, appeal the decision and supply appropriate EBM to support the request for additional treatment. The UR doctors do not have all the relevant medical records when they make a determination as to "medical necessity" per ACOEM guidelines when they receive a request from the PTP for a treatment plan. In this case, if your PTP did give additional info regarding your reaction, it would have been incumbent on the UR doctor to call your PTP and discuss the requested treatment. Maybe s/he did, maybe not. But the UR denial can be appealed. (the PTP has 20 days to make the UR appeal)

    SH. I'm sorry you are wrong.. there is NO contractual relationship between the IW and the IC... the IW DOES NOT pay for a WC policy for benefits when they become injured... therefore there can be no 'bad faith' between the parties. While the IW/EE has a right to be treated fairly, the same an anyone else... there is no legal action to be taken for not being treated as such.
    Being treated with "good faith and fairness" are very different than a 'good faith' relationship where you pay for a service. Do not confuse "good faith" between an EE and ER with 'discrimination' in the workplace, the two are very different.
    And I did check, I happen to have a very astute attorney.

    If you have an opinion you are certainly welcome to offer it here or any where else you happen to frequent... but you have no right here or elsewhere to tell anyone they are wrong when offering their opinion.
    Get off my ass, or stay out of California...you're not the god/dess here and are not the one to detemine wright vs wrong.

  9. #9
    Join Date
    Oct 2006
    Posts
    9,108

    Default Re: Refuse to take epidural injection

    thankx LA for the motherly attempt at reconciliation.
    we are not both correct.
    my experience is different then yours.
    I'll continue to offer information and let others censor the facts they think an injured worker needs to hear.
    Last edited by .SH; 11-08-2007 at 12:03 PM.

  10. #10
    Join Date
    Feb 2007
    Posts
    550

    Default Re: Refuse to take epidural injection

    Like my law professors used to say, "Chapter and Verse" In the law we don't profess that our opinions are fact, unless we can back them up with case law, statutes, etc.

    There is case law on this, SH, and the BAR IS EXTREMELY HIGH. Your average IW would NEVER be able to bring a COA for something like failure to provide med tx. (Unless as I stated earlier they ended up in a wheelchair, and could prove bad faith.)


    LA

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