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  1. #1
    Join Date
    Aug 2007
    Posts
    12

    Unhappy Settle Before Surgery

    Please provide any thoughts, comments....
    In June, 2006 husband left work notifying his employer of significant pain in fingers, wrist, and elbow to the shoulder. He followed up with his doctor next day and provided his employer with detail as requested. January 2007, he consulted with the IME who believed it was a competent work injury but because there were not prior complaints, IME denied the shoulder injury as being work related. The shoulder complaint was on the documents that were provided to the employer for the initial injury complaint and in 3 doctor's records thereafter but where not provided to the IME. In August, 2007 the IME was provided a training video of work duties and then provided an addendum stating he was definitely sure it was not work related. During these 4 years, husband had to file for SS and was approved....(he worked for his employer for 28+ years, clean record). Now opposing counsel is requesting that he settle the claim.
    He still needs surgery for the carpal tunnel release, surgery for the shoulder injury, surgery for the knee replacements, unrelated to WC. How can he settle when in fact he has not had the approved carpal tunnel surgery? And if he settles and has some long term issues thereafter, what happens then? Must he settle or should he wait? The doctor will not perform surgery until his shoulder bills are paid a situation pending at his employer’s benefits area. We know the shoulder is work related but since it was denied, then his employee benefits where asked to cover the cost. He never received a dime from workers compensation since he left work that June, 2006 day. And he was terminated from his employer in Feb, 2009. Any advice would be so much appreciated!!

  2. #2
    Join Date
    Aug 2007
    Posts
    504

    Default Re: Settle Before Surgery

    Quote Quoting smurfd View Post
    Please provide any thoughts, comments....
    In June, 2006 husband left work notifying his employer of significant pain in fingers, wrist, and elbow to the shoulder. He followed up with his doctor next day and provided his employer with detail as requested. January 2007, he consulted with the IME who believed it was a competent work injury but because there were not prior complaints, IME denied the shoulder injury as being work related. The shoulder complaint was on the documents that were provided to the employer for the initial injury complaint and in 3 doctor's records thereafter but where not provided to the IME. In August, 2007 the IME was provided a training video of work duties and then provided an addendum stating he was definitely sure it was not work related. During these 4 years, husband had to file for SS and was approved....(he worked for his employer for 28+ years, clean record). Now opposing counsel is requesting that he settle the claim.
    He still needs surgery for the carpal tunnel release, surgery for the shoulder injury, surgery for the knee replacements, unrelated to WC. How can he settle when in fact he has not had the approved carpal tunnel surgery? And if he settles and has some long term issues thereafter, what happens then? Must he settle or should he wait? The doctor will not perform surgery until his shoulder bills are paid a situation pending at his employer’s benefits area. We know the shoulder is work related but since it was denied, then his employee benefits where asked to cover the cost. He never received a dime from workers compensation since he left work that June, 2006 day. And he was terminated from his employer in Feb, 2009. Any advice would be so much appreciated!!
    I would never settle until I received all medically necessary treatment. Once you settle any future medical treatments on the approved WC injuries will come out of the IWs pocket. No medical insurance will pay for it.

    If you don't have an attorney you really need to get one. Sounds like the IME has effectively stopped any progress for the needed CT surgery by having the shoulder portion of the claim denied. If you do have an attorney you need to put some preasure on him/her to get before an arbitrator to get the shoulder included in the claim.

    beachgirl

  3. #3
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Settle Before Surgery

    Agree with BG, but to add a bit more to your pile here. He is Medicare eligible, therefore, you can't close the comp medical until/unless you address Medicare protection in the settlement, that may require a WCMSA/setaside arrangement for the FMC/Future Medical Care he may need.

    He should be asked to sign a SSA/Medicare release of information form so the current status can be determined, Before and negotiations take place.
    If Medicare has made any conditional payment, those monies must be reimbursed to CMS prior to settlement.

    There are more issues in closing a comp claim that simply taking a lump sum of cash.
    IMO... consult with an attorney who is fully familiar with the new mandates of the MSPA/Medicare Secondary Payor Act, and include a MSA vendor who will address the WCMSA issue. This should be done before any movement in money discussions.

  4. #4
    Join Date
    Aug 2007
    Posts
    12

    Default Re: Settle Before Surgery

    BeachGirl, my husband is working with his second lawyer, first one was let go due to lack of communication. He asked his current lawyer to present in front of arbitrator but lawyer claims he would lose because decision to include shoulder injury as “work –related” must come from his shoulder surgeon. Well his shoulder surgeon couldn’t grasp husband’s job responsibilities and did not feel comfortable stating it was job related plus he did not get paid. Husband’s primary was willing to step up but lawyer did not accept.
    Therefore, only his carpal tunnel surgery with “ectomy” has been approved and now waiting for bills to be paid. Do you believe it is too late in the game to obtain another lawyer? We appreciate your comments because we realize you know your stuff!! Thanks so much for your time!!

    BvIA, thank you so much for the provided information! Husband did sign a SSA/Medicare release form but we did not know what the request was for/was about and thought WC wanted to look in his record to take more out of him. This is simply due to the brow beating received from WC all these years. Your comments allowed us to research the information for much needed understanding and we appreciate your feedback!! He will be talking to his lawyer to ensure the WCMSA issue is covered! Thank you for your time!!!

  5. #5
    Join Date
    Aug 2007
    Posts
    504

    Default Re: Settle Before Surgery

    If you want the name and number of another attorney PM me.

    beachgirl

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: Settle Before Surgery

    The problem with finding another AA/applicant atty, is the fee schedule. Fees are limited based on recovery/award. The more AA's, the less each is paid. You/IW pays but one fee.

    The rules of this board ban the referral of attys by name on the public threads.... use the PM feature for BeachGirl...

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