State Fund Time Limits on Claims

[jdatlarge]

My workers compensation claim was made in the State of: California

History:
I was injured on the job on October 2 2007, I reported the neck and back and shoulder pain to the contractor. I have had to deal with back pain all my adult life and I continued to work but only as management and not do physical labor, except on occasion. A month later it was discovered that the contractor (#1) had lied to the client/property owner about his own WC coverage which was a condition of the job and some other matters. In fact I do not know the status of my WC insurance coverage at the time because of the #1 contractor’s fraud. And some months later, I was a witness against the #1 contractor as the client sued him. The #1 contractor settled by paying the client back money. I continued to work on the job under another contractor (# 2) and the job ended June 2009 and I had further aggravated and or injured my back and shoulder several times while working for #2 contractor. Since the injury I had been taking a muscle relaxer (soma) and paying for massage therapy for my back and neck and tolerating the shoulder pain. In August 2009, while sleeping on my injured shoulder, it popped out and was partially dislocated. I called and emailed the #1 contractor at the time of the injury and waited for his response. He has never responded to me but after I mentioned on a phone message that I would seek legal remedy, he notified the WC insurer who called me. To date the insurer has not denied my claim and has authorized a medical exam and x-rays and an MRI and a second opinion from another doctor. I understand that the insurer is investigating the events of the injury.

My questions:
1. What is the law regarding my claim which I report immediately but did not see a doctor, but I went to a licensed massage therapist without knowing the extent of my injury ?

2. What are the time limits for WC insurance to cover injuries ?.

3. What am I missing, what question should I be asking ?

[BvIA]

1. What is the law regarding my claim which I report immediately but did not see a doctor, but I went to a licensed massage therapist without knowing the extent of my injury ?

The claim is filed with your ER. That is your org DOI/Date Of Injury. When you file a first report of injury, that is when you seek treatment. Why didn't your 'employer'' ("not contractor'') provide the information for you to seek treatment.... ? Was the injury not serious enough at the time to seek treatment ?

2. What are the time limits for WC insurance to cover injuries ?.

Your injuries are not ''covered'', the ER is the insured party, you are the receipient of the benefits. The carrier has 90 days to investigate your claim, you are entitled to treatment up to 10K during that time.

3. What am I missing, what question should I be asking ?

Hard to say, so far it's pretty confusing on who has liability here... ''contractor'' 1 or 2....
And, now that I tried to answer this initially, I'm gonna try to understand another way...

History:
I was injured on the job on October 2 2007, I reported the neck and back and shoulder pain to the contractor.Did you seek treatment at that time ?
That is your orginail DOI for the claim.

I have had to deal with back pain all my adult life and I continued to work but only as management and not do physical labor, except on occasion.

A month later it was discovered that the contractor (#1) had lied to the client/property owner about his own WC coverage which was a condition of the job and some other matters.
The #1 contractor settled by paying the client back money.

I continued to work on the job under another contractor (# 2) and the job ended June 2009 and I had further aggravated and or injured my back and shoulder several times while working for #2 contractor.Your orginial 'contractor #1, is still liable for the injury you reported. As there is a second 'contractor' now, there could be shared liability as the org claim had not been settle out.

Since the injury I had been taking a muscle relaxer (soma) and paying for massage therapy for my back and neck and tolerating the shoulder pain.So, you never sought treatment under the org comp claim...(?) In August 2009, while sleeping on my injured shoulder, it popped out and was partially dislocated. I called and emailed the #1 contractor at the time of the injury and waited for his response. He has never responded to me but after I mentioned on a phone message that I would seek legal remedy, he notified the WC insurer who called me.

To date the insurer has not denied my claim and has authorized a medical exam and x-rays and an MRI and a second opinion from another doctor. I understand that the insurer is investigating the events of the injury. Something is getting skewed here... The carrier has 90 days, as I described above, to investigate the claim, that is why they are authorizting the treatment requests...BUT, when'/IF there is a disputed medical issue, YOU are supposed to be offered the opportunity to select that second opinion Dr. There is a legal process to follow here.

Now that you have provded 'history', please try to post one or two questions at a time, and break up the block of words...easier to sort out.

Have you missed any time at work yet ?
Have you been asked to select a PTP within the MPN/Medical Provider Network?
Has it been determined that your ER (#1) actually DOES have coverage or NO ? That is were I'm confused, you said there was a problem where he lied, then he supposedly notfied the IC who contacted you... which ER's ins company contacted you...

[jdatlarge]

Thank you for your help.

ER means employer, correct.

Correct: The #1 contractor was my employer at the time of my injury. I continued to work for #2 contractor after #1 contractor was fired.

Also, I continued to work because I did not feel that my injury was not much worse than the back pain that I have experienced over 40 years in construction (I’m 61) and I continued working for two reasons, there was a quadriplegic injury on the same job a year earlier so I felt that I should buck-up and.......I did not want to give up the job, I started the job and I wanted to finish it.

Your comments have helped me understand that #1 contractor failed to report my injury and because he doesn’t like me because I told the truth and testified against him, he most likely is giving erroneous information to the insurer. I am confident that once the insurer investigates the matter and talks to the witnesses at the time of my injury, the insurer will pay for my surgery.

The bottom line is that it will be my word against #1 contractor and I’m ok with that. #2 contractor supports my position as he witnessed my injury.

[BvIA]

The bottom line is that it will be my word against #1 contractor and I’m ok with that. #2 contractor supports my position as he witnessed my injury.

You should be ready, along with #2, to see the carrier for #1 bring joint liability here...it will be difficult to seperate the injury from one to the other... if the carriers are the same, it won't make any difference.

It really won't make any difference to your claim one way or the other.

But, you should also expect a denial, and a trip to PQME for a medical/legal evaluation.

IF there is any resulting permenant disability due to this injury, any award will be reduced by the % the treating physican feels, with supportive medical reasoning, the prior 40 years of ''suffering'' back issues contribute to the PD/impairment. From what you say here...that could reduce your potential award downward significantly.

[disappearingboy]

"ASKED to SELECT a PTP"???

rofl!!! Anyone who is treated that well might just recover OK.

[BvIA]

"ASKED to SELECT a PTP"???

rofl!!! Anyone who is treated that well might just recover OK.

When an EE files a first report of injury in Calif, the ER/IC provides directions to access treatment... They are premitted to form a MPN/Medical Provider Network, much like a HMO.
If the ER/IC sends the IW for treatment to say a clinic, and the doctor there treats, that is the "PTP"... after 30 days, the IW is permitted ... "ASKED to SELECT a PTP"??? of their choice. Change of PTP up to 3 is allowed, in the MPN.

[jdatlarge]

Gentlemen, thank you for your help and advice, and I admit to having trouble figuring out what the acronyms mean that you are using, having never dealt with WC before this injury.

Yesterday, the insurer authorized a second MRI as well as the surgery for my dislocated shoulder.

One of the two doctors that I saw said something about disability, and I am not scheduled to see him for two more weeks.

Do you have an idea what kind of disability he may be talking about?

Could it be the period of convalescence after the surgery or permanent as mentioned in your prior comments?

And can you tell me if it's State or Federal disability for this kind of injury?

Over the years, my chronic back problems have been remedied by massage and pills and time off but I will understand any overview by adjustors to include my past with any settlement.

Bottom line, I'm grateful to have the insurance and thank you again for your help.

[BvIA]

Do you have an idea what kind of disability he may be talking about? And can you tell me if it's State or Federal disability for this kind of injury?

When the Dr talks about 'disability' it means a evaluation of your condition, and calculation of permenant disability/impairment you suffer as a result of your work injury. That 's the number the state uses to determine the amount of money/indemnity you are due for this injury. The % is your loss of ability to compete in the open labor market...you are not actually ''disabled'' per se...its a tool to calculate the dollars.

Your prior physical difficulties will be taken into consideraton when the Dr issues the final report...it's called apportionment to cause. Your ER is liable for the % of PD due to this injury... not for what you may have as impairment prior to this incident.

Bottom line, I'm grateful to have the insurance

You don't.... the insurance coverage is for your ER/employer, who is liable for your injury... ER's can be covered by policy purchased from an IC, or self insured by posting bond. The coverage is for the body part you claim injuryed... not like your personal health coverage... not the same at all.

[jdatlarge]

Latest development:
An abnormal mass was discovered at the base of my head and at the point of injury. I need more immediate care instead of waiting the 5 day allowed delay by State Fund.

I cannot wait for State Fund to evaluate and revaluate and fool around, I am going to evoke my private health insurance policy and sue State Fund with the intention of forcing them to change their system for cases like mine.