Denied Medications and Treatment

[stephenhonda]

My workers compensation claim was made in the State of: California
hi my name is steve and ive been suffering from a bunch of problems in my left arm caused from work its been tooth and nail fighting with my workers comp insurance ever since my injury in 2003 they constantly deny my medications doctors visits and other related expenses ive been seen by an AME that workers comp sent me to and he diagnosed my injury and told me to go see a specialist in orthopedics they also stopped my temporary disability payments im at my wits end dealing with workers comp and the insurance provider ive been to 8 doctors 2 AME's and still cant get my injury fixed im in constant pain and under heavy work restrictions ive also had to get a lawyer and still im not getting proper medical treatment my lawyer told me to file state disability to try to curb the money problems caused from not being able to work full time and the stoppage of my temporary benefits my claim has went nowhere in 5 years and im thinking of sueing the system any advise that can help me deal with any of these issues is much needed my temporary benefit were supposed to be for 104 weeks and i only received 24 weeks worth i thought workers comp was supposed to help injured workers make a full recovery and return healthy to the work force but there causing my injury to progress and still no help my medical conditions are as follows

left shoulder suprascapular nerve palsy
and impingment syndrome with significant muscular atrophy

please help if anyone can advice is much needed and thing else you wanna know just ask and ill post it

thanks steve

[BvIA]

If your PTP says you cannot work due to your injury, your TTD is not for 104/wks in your case... but rather for a period of 240 weeks with in 5 years of your DOI...

4656(b) Aggregate disability payments for a single injury occurring on
or after January 1, 1979, and prior to April 19, 2004, causing
temporary partial disability shall not extend for more than 240
compensable weeks within a period of five years from the date of the
injury.http://www.leginfo.ca.gov/cgi-bin/di...file=4650-4664

Fortunately in your case, the TTD can start/stop, but depending on what month you were injured, you have reached the cap..its now 5 years post DOI...that may be the reason your TTD has stopped....(?)

they constantly deny my medications doctors visits and other related expenses

There must be a medical determination for your treatment requests to be denied, as well as be authorized...Your PTP is charged with developing a treatment plan, and submitting the appropriate requests for treatment.

ive been seen by an AME that workers comp sent me to and he diagnosed my injury and told me to go see a specialist in orthopedics

Did you see the orthopedic doctor...per the AME ?
That doctors report must be submitted to the AME, and incorporated into the final report the primary AME would issue.
If there was/is a disputed medical issue, that would be the reason for an AME to become involved....

You say you have been working, presumable with restrictions placed on you by your PTP...
If you are due TPD/Temp Partial Disability payments, they would be due as follows...

4654. If the injury causes temporary partial disability, the
disability payment is two-thirds of the weekly loss in wages during
the period of such disability. However, such disability payment
shall be reduced by the sum of unemployment compensation benefits and
extended duration benefits received by the employee during the
period of temporary partial disability.

Your attorney is correct in your filing for SDI benefits...you can receive these for up to 12 months when there is a problem with the WC benefits.

As you do have an attorney, and have been evaluated by an AME, we'd have to presume that your AA has filed the DOR for expediated hearing for a judge to make a determination on the dissputed issues in your claim.

There really isn't anything for you to do at this point but file for the SDI, and wait for the hearing to take place...

ive been to 8 doctors 2 AME's and still cant get my injury fixed im in constant pain and under heavy work restrictions ive also had to get a lawyer and still im not getting proper medical treatment my lawyer told me to file state disability to try to curb the money problems caused from not being able to work full time and the stoppage of my temporary benefits my claim has went nowhere in 5 years and im thinking of sueing the system

There is more going on here that what you can post..
What is your current disability status...TTD, TPD, P&S/MMI...?
What is the reason/disputed issue for the AME...?
What has the AME reported in the past...?
Is your PTP submitting the proper request for treatment ? and has there been UR denials...?

You can forget your idea of suing the system...who do you think you'd sue..?
The WCAB is your exclusive remedy for a work related injury...the ER/IC is fully within their rights to appeal an AME or judges decision...
Unfortunately, the systme is broken, you've fallen between the cracks of some very bad legislation...and at this juncture, you are in a position to wait this out.

WC medical treatment is not like regular health coverage... and should not be thought of as such...this system is very slow, as most other types of law are...there isn't anything to do to move your case along any faster.

[kelly38]

Steven

BvIA is correct, apply ASAP for SDI...and if you have long term disability coverage now is the time to apply (they may or may not pay for a work related injury, depending on your policy).

I am sorry for everything that you have been through...and I wish you the best of luck.

[MAMMYBOJAMMY]

Hi Steve, I am in KY and the system is no better here. I have been on WC for 21 years. Recently my file was moved from 1 State to another. When it reached its final destination, the 3 women I have had to deal with cannot be getting any sleep, if they have any conscious at all!

For the 1st time in 21 years, I have been without my meds for over a week now. The last 2 months I have had to pay for them myself. At over 400.00 per month, I just cannot afford that. I'm sure you can relate to what I am saying.

How old are you, might I ask? If you are over 50, you might stand a good chance of getting Social Security Disability (SSD). You might also be eligible for food stamps, and a few other things, especially if you have any children at home. Talk to someone about it.
The website below will take you to all 50 States rules and regulations. Just click on your State. You do need to be as aware as possible about what the laws are there. I will post the SSD site for you too.

Take Care, and good luck, Mammy

http://www.socialsecurity.gov/disabi...%20any%20cause)



http://www.workerscompensationinsura...inks/index.htm