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  1. #1
    Join Date
    Jan 2010
    Posts
    2

    Default Worker's Comp Denial - Rotator Cuff

    I will try to be brief. My husband injured his shoulder at work, didn't report it right away, thought he could "tough" it out as usual. Went to doctor week later, small tear in rotator cuff. Company HR *refused* to even file it. WC office was of little help. Finally got them to file but was denied. Was receiving short-term disability, my insurance will cover the medical bills.

    There are many examples of how badly they've treated him, not just that they didn't know if he was hurt at work, but that he is a liar. 13 years of working for them and not complaining about his aches and pains and the wear and tear on his body. (Dumb, I know.) He is finally back to work after a couple of months and some PT.

    The doctor put down that he said that it was work-related, but I don't believe the doctor can testify one way or the other.

    One thing -- a few weeks after his claim, they made changes in the job he told them he was doing to allow less pressure/weight on the arm while doing it. They also made changes in another job that he does most of the time that also puts less weight on the shoulder. Out of the blue. One of the things was something he had suggested previously.

    So, there we stand. He is trying to find another job, but they will certainly ask about injuries. Wondering if we should pursue it, go for the hearing, hire a lawyer.

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

    Default Re: Worker's Comp Denial - Rotator Cuff

    The doctor put down that he said that it was work-related, but I don't believe the doctor can testify one way or the other.
    Nearly everything in WC is based on the opinions of Dr's, and the statements of the EE/IW... WC is no fault. You do NOT have to prove you were injured at work...the injury must meet AOE/COE though...Arose Out of your Employment, and in the Course Of your Employment/job duties.

    When you file a claim for benefits under the ER's plan for industrial injury, they must file a claim with their IC providing the coverage.
    It is your employer’s responsibility to report your injury/illness to his/her insurance carrier or claims administrator. The insurance carrier will then report your injury/illness to the Wisconsin Worker’s Compensation Division.

    In the event you are hurt at work or become ill, it is your responsibility to:

    ■Tell your supervisor that you are hurt immediately, even if you think your injury is minor and will heal without medical attention.
    ■Obtain any necessary medical attention. Which may be getting first aid, seeing a doctor or going to the emergency room.
    ■Maintain all relevant medical and payment records for possible future use.
    You should act to notify your employer and get medical attention without delay. A delay may negatively affect your health and may even jeopardize your potential workers compensation benefits. Failure to report your injury/illness to your employer within two years could result in your claim for worker’s compensation benefits being barred. http://www.dwd.state.wi.us/wc/workers/fileaclaim.htm
    The HR dept was wrong in not filing the claim.

    The problem with ''toughing it out'', you are not liable for the medical or wage loss in a work related injury, as such, you/your own GHP carrier are not to pay the bills. When the Dr bills your GHP for services to a industrial injury, that carrier is likely to deny coverage. The STD carrier may or may not pay for wage loss due to a work injury. "Toughing it out'' could cause all kinds of difficulty.

    You should pursue this claim. If there is resulting permenant impairment from this injury, there is probably indemnity payment due. But more than that, if there were further injury with this ER, or a future ER, the impairment due here would reduce the potential award the next time. He/you deserve the indemnity payments if the injury is compensable.

    Information on WI WC is here http://www.dwd.state.wi.us/wc/workers/
    So, there we stand. He is trying to find another job, but they will certainly ask about injuries. Wondering if we should pursue it, go for the hearing, hire a lawyer
    IF there are any restrictions defined by the Dr, he should not seek another job outside those restrictions. Otherwise, he does not have to disclose the fact there was a WC claim, or injury prior to an offer/acceptance of employment.

    Talk to an attorney, there is no cost, and find out the merits of this claim. At least you'll have the comfort of legal advise.

  3. #3
    Join Date
    Jan 2010
    Posts
    2

    Default Re: Worker's Comp Denial - Rotator Cuff

    Further question/verifying what I've read on this forum:

    My husband is applying for other jobs. He can't stand working there anymore. It will mean a pretty substantial cut in income, but for his sanity he needs to get out of there.

    If he switches jobs and has further trouble with his shoulder, it will be considered another injury, not a continuation of the original injury? So he'd have to file with his new employer?

    If we appeal the company's insurance carriet's decision to deny, the most he can hope for is full payment of the medical bills over and above my medical coverage? (There were maybe $4000 in bills, my insurance has said they will cover 85%, if the WC is denied, so maybe $600 paid by us.) He received short term disability for the 2 months he was off.

    So is it worth it to go ahead with the appeal? To hire a lawyer, even for an hour of his time to ask for advice before the hearing? Or maybe my insurance carrier will require us to go ahead with the appeal?

    Any info you can give is appreciated. The paperwork, red tape and bureaucracy is mind-numbing.

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

    Default Re: Worker's Comp Denial - Rotator Cuff

    WC is all about liability. Who is to pay the bills.
    If the injury is accepted as industrial, then you are not lilable...meaning your IC is not supposed to pay the bills. (You buy health coverage the same as ER's buy comp insurance...to limit the financial exposure for injury/illness)

    So, yes it would be to your advantage to pursue the comp claim.

    So is it worth it to go ahead with the appeal? To hire a lawyer, even for an hour of his time to ask for advice before the hearing? Or maybe my insurance carrier will require us to go ahead with the appeal?
    It's not a matter of being 'worth' it. There would be no cost for consultation with an attorney. You'd find the merits of the claim and how the dispute process works.

    The coverage for his injury remains open as long as a Dr can provide medical evidence to necessity. If the claim is eventually denied, then you will carry the liability.
    If accepted, the ER/IC does, and if he changes ER's the coverage continues....Unless there is new injury. In that case, the new ER would be liable for the new injury, BUT, any rating/money received from this claim would be subject to apportionment in the new claim. ER's are liable only for the PD/impairment due to the injury suffered on their watch.
    If we appeal the company's insurance carriet's decision to deny, the most he can hope for is full payment of the medical bills over and above my medical coverage? (There were maybe $4000 in bills, my insurance has said they will cover 85%, if the WC is denied, so maybe $600 paid by us.) He received short term disability for the 2 months he was off.
    When you file a claim for WC benefits, the medical treatment should be provided at no cost to the IW... while the claim is filed by the ER with their IC, and there is investigation. Even if the claim is denied, there should be no cost for that treatment up to the denial.
    YOu have a duty however to pursue a denial through the system. Just because the carrier says 'no', isn't always the end of it. A judge has the authority, with the medical evidence to order the claim compensable. In the end, you/your IC may or may not be liable...and your duty is to your IC to limit their exposure just as your own.

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