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  1. #1
    Join Date
    Dec 2007
    Location
    Montana
    Posts
    2

    Angry Adjuster Approval Time

    In live in Montana and I was injured in 09/07. Several issues with my WC insurance adjuster doing things in a timely manner. First, they did not issue my first benefit check until I called 30 days later asking where it was. They told me I could not get a second opinion without approval and would not approve it. On average, it has taken 2 weeks to get approval for therapy, tests, treatment and to see doctors I have been referred to by my initial treating physician. (I call and leave VMs and emails daily). I have had problems getting medications I need approved in what amounts to up to a week. Does anyone know if there is a law specifying how long WC can take to approve these things? I have to suffer in debilitating pain for weeks until they approve something. Also, it eats away at the FMLA time I have to get better and could result in me losing my job. Thanks in advance for any insight on this.

  2. #2
    Join Date
    Nov 2007
    Posts
    197

    Default Re: Adjuster Approval Time

    welcome to wc hell. although im not from montana, its the same everywhere. what you are experiencing is "normal" for wc. they do not care about the injured worker. what they are doing is hoping that you will get ticked off and go to your own dr, so that they dont have to pay your medical or any other benefits anymore. if you venture out on your own...you lose ALL wc benefits, including your weekly checks.

    the laws are different in each state, so my best advice to you is...consult with an attorney. here in nc, we are entitled to a 2nd opinion, BUT its not for treatment...but for the rating!! and no, wc most likely is not going to willingly send you for. (i had to get my attorney to get that set up for me) the laws are different in each state, so things may be different...but here in nc....you CANNOT lose your job. if your dr has written you out of work...you cannot go back until you have seen a dr that says you can go back to work....so your job has to deal with that. there are sooo many circumstances, so many ifs ands and buts....that you REALLY need to seek the advice of an attorney.....a WC specialist...not just any attorney. you may not think you need one...but trust me...YOU WILL need one.

    PLEASE...keep a daily journal starting from day 1 of your injury....how it happened, who you told, who sent you to what dr...what did that dr say/do....who you talked to at WC....what they said, etc...document EVERY SINGLE THING related to your injury. even the very minor things need to be written down.....leave nothing out. TRUST ME...this WILL come in handy later on. TALK WITH AN ATTORNEY!! WC makes bets on it that injured workers doesnt know the law, doesnt know what all they are entitled to...and bank on it that most people wont look into it. Trust me when I say this....WC will spend $10,000 in legal fees to fight to send you to a dr for a $2000 procedure.....I know...its crazy!!!...but thats how they operate.

    i have been dealing with wc for over a year now....i was referred to see a neurosurgeon 6 months ago.......STILL WAITING!!! but before that....the "normal" waiting period to see a dr that i was referred to was at least a month. yes, it leaves you in one heck of a predicament.....in lots of pain, needing care.....but no dr to go to....it really sucks!

    PLEASE seek an attorney. I dont know about Montana, but here...they do not get paid unless they win your case....so check into that if thats worrying you about hiring an attorney. Good luck....hope you get to feeling better.

  3. #3
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Adjuster Approval Time

    As Workers Compensation laws are state specific, you should begin by making yourself familiar with those laws/rules...you can find your state information on WC here...http://data.opi.state.mt.us/bills/mca_toc/39_71.htm


    "39-71-107. Insurers to act promptly on claims....'', is specifically covered by Montana laws...
    http://data.opi.state.mt.us/bills/mc.../39-71-107.htm

    Here is just a small portion of the page sited above, but may help with some of your questions...
    (b) The department may assess a penalty not to exceed $200 against an insurer that does not comply with the advance notice provision in subsection (4)(a). The penalty may be assessed for each failure by an insurer to give the required advance notice.
    (5) An insurer shall provide to the claimant:
    (a) a written statement of the reasons that a claim is being denied at the time of denial;
    (b) whenever benefits requested by a claimant are denied, a written explanation of how the claimant may appeal an insurer's decision; and
    (c) a written explanation of the amount of wage-loss benefits being paid to the claimant, along with an explanation of the calculation used to compute those benefits. The explanation must be sent within 7 days of the initial payment of the benefit.
    (6) An insurer shall:
    (a) begin making payments that are due on a claim within 14 days of acceptance of the claim, unless the insurer promptly notifies the claimant that the insurer needs additional information in order to begin paying benefits and specifies the information needed;


    As I said, you should go to the site and make yourself familiar with the laws, and file any complaints with the Montana WC Court...the penalties can add up...
    Once you are familiar the the law covering your issue, you can then cite the law/rule to the CA when something out of line occurs...you'd be suprised how fast things can happen when an IW is versed in how things are supposed to work...CA begin to respond positively. But you MUST follow up with the appropriate complaints to the WC court.
    As you are recovering from your injury you have lots of time to become a "willing participant'' in your own case. IF you do find you need an attorney you'll be ahead of the game on your initial consultation.

  4. #4
    Join Date
    Aug 2007
    Posts
    60

    Default Re: Adjuster Approval Time

    I had the same problem too.......my adjuster would NOT call me back, would take FOREVER to approve a surgery I could have had a month earlier if they had approved it in a timely manner. I totally hear ya about the checks, AND being in excruciating pain while you are waiting!

    Get a lawyer and like BIVA says, know your laws b/c they do think you don't know what you are talking about. I told my adjuster that I was entitled to a second opinion and I WASN'T going to wait forever, so they better pay for it, and better approve it. They had 2 weeks to approve my 2nd opinion and STILL didn't by the time I got there. I told the adjuster I was seeing the dr. anyway and he better approve it by the time my appt. was over. I have no idea what happened but I never got a bill.

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