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  1. #1
    Join Date
    Jun 2007
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    20

    Question QME States "Unable To Return To Work"

    Injury is 2 years old Rec'd SDI for 12 months. Surg prominate rt shoulder 8/07 after QME stated was necessary and confirmed I was T disabled had/bilateral CT as well as impengement rt shoulder, I finally started receiving TTD. In Jan 2008 same QME found me 8% total body disabled and P&S for shoulder, no apportionment totally disabled 100% rt shoulder. Also unabled to return to work. Noted Bi lateral, repetitive injury claim still open. I've not received a dime since. Still waiting. I can't figure out whats going on. Can someone explain? The repetitive injury is a different clain and W/C is fighting.

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,018

    Default Re: QME States "Unable To Return To Work"

    In Jan 2008 same QME found me 8% total body disabled and P&S for shoulder, no apportionment totally disabled 100% rt shoulder. Also unabled to return to work.

    The 8% is your WPI or "Whole Person Impairment" to your shoulder...you are not "100% disabled''...it may be "100% work realted'', and as you say ''no apportionment'', which means there are no outside issues to causation to the disabilty. The 8% WPI will be the determining factor to the value of your ''award'' for the PD indemnity.
    As you are unable to RTW, you would be eligible for the SJDV..'voucher', to assist you in honing your present job skills, or re-training, or job placement assistance...there is no more "VR"...per se.



    '' Noted Bi lateral, repetitive injury claim still open. I've not received a dime since. Still waiting. I can't figure out whats going on. Can someone explain? The repetitive injury is a different clain and W/C is fighting. ''

    "Bi later'' to what body part...? If you are refering to the 'shoulder', the QME (was this a Panel QME) declared you P&S to the 'shoulder', and that is why you are not receiving any 'money', or TTD benefits. As there is a dispute, it should go to a judge to make the determination, or back to the PQME for a supplemental/clarification to the meaning of ''Noted Bi lateral, repetitive injury claim still open''

    How is the bi lateral issue a different claim vs the rt shoulder injury ?
    How was this filed that makes it a seperate claim...

    You need to supply more information here... what you are saying isn't clear to your situation, making it difficult to opine further...(?)


    ''Injury is 2 years old Rec'd SDI for 12 months. ''

    What happened here...?
    Was the SDI, TTD cleared up...? You can't receive SDI and TTD for the same period, you need to clarify this as the EDD will place a lien against your potential award if the SDI is not reimbursed, as TTD should have been paid for the period the PQME determined your eligibility for the benefits.
    WHY were you receiving SDI ?....once you file a claim for WC benefits, the ER/IC only has 90 days to accept/deny the claim... was your claim initially denied...?


    '' I can't figure out whats going on. Can someone explain? ''

    Not really, until you provide some clearer information to what is happening in your case....(?)

    DOI
    What doctors have you actually been evaluated by ...you say "QME" was this a Panel QME, or what ? How was it you saw this doctor in the first place....?
    How did there come to be a second claim...and what is/was the DOI for that ?
    HOW is that 'dispute' being addressed...
    ''The repetitive injury is a different clain and W/C is fighting. '' "Fighting"...? What does 'fighting' mean...?
    ''Still waiting. ''
    Ok, What are you ''waiting'' for...?
    Has the claim been denied...?
    Have you requested to return to the PQME for a determination to the denial/disputed issue ?
    How long has this been denied ? There are specific time lines here were you must present your objections...you can't just ''wait'' until ''someone'' comes along and says..."what do you want to do now?"

  3. #3
    Join Date
    Oct 2006
    Posts
    9,109

    Default Re: QME States "Unable To Return To Work"

    for information about impairment benefits:
    http://www.dir.ca.gov/dwc/FactSheets/FactSheet_D.pdf

    contact your I&A officer for help in filing for hearing to have additional benefits awarded.
    http://www.dir.ca.gov/dwc/IandA.html

  4. #4
    Join Date
    Jun 2007
    Posts
    20

    Default Re: QME States "Unable To Return To Work"

    Bvia, thanks for the questions. I'll try to explain.
    Shoulder fracture is from 4/05, apparently from surgery report of 8/07 I had a slap tear and completely torn labrum with detached tendons. At the time of the 4/05 injury I continued to work, in soft cast. No time off.
    That W/C Ins Co kept changing doctors I was to see.
    Developed RSA right hand and arm in Apr 06, con't to work until I could no more. I did not know what RSD meant. 6/2006 I took off from work on a W/C claim for repetitive stress, to hands and right arm , and shoulder.
    This Claim was with a new provider for W/C Ins.
    I continued to see the W/C phy for my shoulder, different than for the repetitive injury claim, until he retired and tried to P&S me, before I had my surgery, all agreed had to happen. This physician verbally told me to file a new claim for my repetitive injury with the new carrier.
    As time passed the New Ins Co for the repetitive injury claim said the other W/C Ins Co was responsible for both injuries.,
    I retained an attorney for both claims. We had depositions 4 parts. Attys from both W/C Co.'s were present, then the employer threw in a lie which resulted a 132A.
    Continued for almost a year, with reschedules, changes, my attorney filed a 132a against employer, who eventually stated I quit, then changed it to they fired me, they eventually have dropped that fight, and dropped the other attorney they'd hired for that, whom never showed up as we waited at each scheduled depo.

    I was sent to the PQME for the first injury 5/07, his report said I was TTD. Needed surgery to right shoulder. He also stated in his report that I had been Diagnosed by 4 different doctors with RSD right arm, and noted there is a repetitive injury claim for the bilateral CTS not related to the shoulder claim. He confirmed I had Bilateral CTS. W/C does not acknowledge RSD so I had to get treatments on my own. (the W/C Law didn't acknowledge RSD or something)
    I had shoulder surgery 8/07 and began receiving TTD from the date of surgery. From Jun 06 until exhausted Jun of 07 the only income I had was from SDI, whom placed a lein against the first W/C carrier. The SDI was less than the TTD amt.

    The previous year while receiving treatments for RSD my arm became Atrophied, I lost the feeling in my right hand completely with pain from elbow to fingertips, unbearable, lots of shots and pain meds, my hand is smaller, and turns under. I was told there was no way anyone would do surgery during that time, couldn't.

    After a clear bone scan, I paid for,
    I had surg on my shoulder that is the 8/07 surgery W/C paid for.

    In the meantime the other new W/C Ins co. for the repetitive injury claim, sent me to their AME who stated I didn't have bilateral CTS, and did not have a repetitive injury claim. He said it was denied because I quit my job.

    Then I was sent back to the first W/C injury PQME for the shoulder who repeated I could not return to work, and I was disabled. Could care for myself only. 100% industrial caused. He noted again the repetitive injury claim posted prior to my leaving work.

    My attorney said the PQME would need to state what my modified work duties would be.
    I was P&S.
    Both the Insurance Co and My atty requested a supplemental clarification.
    PQME responded, I've reviewed the surgeons report, and the neurology report I stand with my final P&S report. 8% WPI as to the shoulder. 100% Industrial caused. No apportionment. Unable to return to work.
    Able to care for herself only. Con't therapy and Medical when needed.
    When I saw him I did not have feeling in my left hand. He spent a lot of time with me.
    I don't want to lose the use of my left.
    I barely drive and can't hold the phone now.
    I don't want sympathy. I've accepted my disability.
    On second claim for repetitive injury the attorney stated she has ask the AME to change his report, and supplied him with the PQME reports.
    I may have to wait and see a PQME on that claim.

    So now no income at all. Because the W/C Ins
    for the shoulder doesn't understand what the PQME is saying, even though the W/C Ins Co Atty suggested I work at the movie theatre showing people where to sit with a flashlight.

    The PQME noted the bi lateral CTS and atrophied right arm and hand. He referred back to the neurology reports for RSD, and treatments. He completely disregarded the AME for the other W/C Ins Companies report.

    Hope this is clear. I have a hard time, think faster than I move.

  5. #5
    Join Date
    Jun 2007
    Posts
    20

    Default Re: QME States "Unable To Return To Work"

    SH
    I went to the pages you recomended, thanks,
    I think this is tripping me up,

    "Impairment rating: A percentage estimate of how much normal use of your injured body parts you've lost. Impairment ratings are determined based on guidelines published by the American Medical Association (AMA). An impairment rating is used to calculate your permanent disability rating but is different from your permanent disability rating."

    Can you explain what this means to me?
    All help is appreciated.

  6. #6
    Join Date
    Oct 2006
    Posts
    9,109

    Default Re: QME States "Unable To Return To Work"

    This is the general meaning:
    doctors do an evaluation of your recovery and document functional loss due to the injury. under the AMA guides the loss is expressed as percentage of a whole person impairment with 0 being no loss and 100 being total loss.
    the physician's rating is submitted to the state to calculate a disability percentage and the equivilant benefit payments. This is the disability rating also expressed as a percent or in weeks of payments or in total dollar amount.

    example:
    a injured may receive an 8% wpi rating from the doctor which results in a 12% disability (50.25 weeks or $10,050 at the maximum rate)

    I'm not sure what it means in your case; each is different.
    does this help?
    Last edited by .SH; 04-02-2008 at 08:00 AM.

  7. #7
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,018

    Default Re: QME States "Unable To Return To Work"

    I think this is tripping me up,

    "Impairment rating: A percentage estimate of how much normal use of your injured body parts you've lost. Impairment ratings are determined based on guidelines published by the American Medical Association (AMA). An impairment rating is used to calculate your permanent disability rating but is different from your permanent disability rating."


    There is SO much more to a PD/WPI rating ...
    Go here http://www.dir.ca.gov/dwc/PDR.pdf, and you'll find 89 pages to read regard the new PDRS used since the new laws took affect.


    the physician's rating is submitted to the state to calculate a disability percentage and the equivilant benefit payments.

    The rating done by the PTP or PQME/AME doesn't have to be sent to the DEU (state) for a rating...and usually is only done where there is a disputed issue.
    The DEU can do ratings as...
    *Formal, done at the request of a workers' compensation judge
    * Consultative, done on litigated cases at the request of an attorney or DWC information and assistance officer
    * Summary, done on non-litigated cases at the request of a claims administrator or injured worker

    The rating done by PTP/PQME/AME can and is often used for a Stipulated Settlement, or C&R...all 'settlements' must be approved to adequacy by a WCAB judge.

    Where there is a PD % rating, that is converted to the WPI % and the basis for the indemnity payments. "PD" actually is no longer used in Calif. claims.

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