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  1. #1
    Join Date
    Mar 2011
    Location
    Villa Park, IL
    Posts
    1

    Default Switching to Health Insurance to Have Surgery Done

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

    Workers Comp has denied my L4/L5 spinal fusion this has been a ongoing problem since 2009. My spinal surgeon sugestted that I change to my employer health insurance to have this taken care of.

    Will my health insurance pick this up after it was denied from Workers Comp?

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Switching to Health Insurance to Have Surgery Done

    Will my health insurance pick this up after it was denied from Workers Comp?
    Just because the IC has denied doesn't mean the surgery is necessary on a non-industrial basis. Any ER/IC would simply deny if possible, shifting the liability to the IW, and their GHP/Group Health Plan coverage.

    Most IC writhing the GHP specifically exclude work injury from any/all benefits. Only if a WC judge finally determines the ER/IC is not liable would your GHP finally pick up the tab.

    Or, if you can get the GHP to accpet the billing, pay and place a lien against your WC claim, you may be successful in getting that GHP to pay. But, you must get this in writing. Don't just take a GHP rep on the phone saying "ok, we'll do that for ya"...
    Workers Comp has denied my L4/L5 spinal fusion this has been a ongoing problem since 2009.
    Why hasn't this been in front of a WC judge... IL brings a claim in rotation about once every 3 months or so for a status conference. Where is your attorney in this ?

  3. #3
    Join Date
    May 2010
    Posts
    313

    Default Re: Switching to Health Insurance to Have Surgery Done

    wouldnt that be the perfict defenition of " pre-existing condition"???...and wouldnt be covered?

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Switching to Health Insurance to Have Surgery Done

    There are no 'pre existing conditions' in WC.
    We are take "as is" on hire. Aggreviation to a prior injury, or condition would be a new injury/claim. There would be no way for any EE to sign away their rights under the statutes govening the ER/IC liability for industrial injury.

    The whole concept of WC is the ER liability... EE/IW's are not responsible for the costs to treat work injury, that is why GHP doesn't cover. If the GHP covered the treatment costs... the IW would be out of pocket for copays/deductibles ...up to 20% of the cost of treatment. If GHP covered, and ER picked up the out of pocket costs... the ER/IC would be stupified with glee.

  5. #5
    Join Date
    May 2010
    Posts
    313

    Default Re: Switching to Health Insurance to Have Surgery Done

    you missed the point!.....You have a injury(yes wc injury) but Dr thinks the magical fix is to change it to a regulare claim....It is pre-existing...its allready happend in 2009! this is the game that needs to be fixed,,,wc or not wc!

  6. #6
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Switching to Health Insurance to Have Surgery Done

    I didn't miss any point... there no "pre existing" issue in WC.
    Treating an injury doesn't change that.
    IF an injury/illness is "cured", and additonal treatment is required later on...it's still a work injury. GHP is still not going to pay, and if you allow that, knowing the ER is still liable, or you have taken money to buy out the medical, you are attempting to defraud the GHP, and could be charged as such.
    this is the game that needs to be fixed,,,wc or not wc!
    What 'game"... if you suffer injury AOE/COE< the ER/IC is liable for the benefits due....medical care is but one of those benefits.
    You claim work injury, your Dr supports the facts... it is WC.
    Only if you exhaust the litigation process....and a judge finally decides the injury is NON industrial, can you then use your own GHP coverage as YOU are liable for the medical care.
    Dr thinks the magical fix is to change it to a regulare claim
    Dr don't make the decision on liability...only causation.

  7. #7
    Join Date
    Jul 2010
    Posts
    12

    Default Re: Switching to Health Insurance to Have Surgery Done

    This is so incredibly sticky and I don't know what/whom to believe. I'm in California right now, and my attorney told me that GHP HAS to cover treatment, ( if I do a C/R), but that an individual policy may not. I am trying to decide how to settle my case this week. My AA also said that Medicare coverage is ONLY an issue if you are on it now, or going on it within 30 months...at no other time is it an issue for coverage down the line. There is a chance that surgical intervention will not be a real option for years down the line, but I don't really know that for certain...I am so frippin' confused..and don't want to make a major mistake here. I can't be without coverage, yet the IC seems to decline other recommended non surgical treatments.

    May I also say that I did some research at the law library last year, and found a case in CA. that was settled with a C/R . The IW thought his GHP would cover this injury and when he found out the would not, he returned the money, the judge set the C/R aside and I assume he got medical from the ER/IC. So, that seems to contradict what my AA said, although each case may be different...I don't know..

    Help!

  8. #8
    Join Date
    Jan 2010
    Location
    Pennsylvania
    Posts
    609

    Default Re: Switching to Health Insurance to Have Surgery Done

    No BIVA is right. If you accept the C&R settlement...you are releasing the WC IC from liability and you pay out of pocket for your medical care and surgery for your injury. If you allow GHP to pay for the surgery after a C&R down the line that is called double dipping and it IS a criminal offense. You knowingly allowed the GHP to cover a work related injury and kept the settlement money (that was intended for the use of your injury related expenses).

    So...ok...what about this little scenerio here? I hate to think about bad things but what if you do happen to have the surgery with GHP covering? Then something happenes that the surgery does not work for you and you DO have to go under SSDI and was permenantly disabled? You would have to go on Medicare right? Well now the GHP paid for surgery and you got away with it....but what about medicare? The lie continues, and now not only have you commited insurance fraud but now medicare fraud too. Think that if you become permantly disabled that you could survive the 30 months without Medicare to help pay for your expenses.... you won't recieve SSDI to help with income because it's AUTOMATIC that you become medicare eligible 24 months post eligibility. So.... get this right. Please. Anyway, what is the AA doing about petitioning for this surgery?

  9. #9
    Join Date
    Feb 2007
    Location
    Western New York State
    Posts
    1,341

    Default Re: Switching to Health Insurance to Have Surgery Done

    Just to add my two cents that may shed some light on this subject:

    Are your trying to understand a pre existing condition, do you mean a pre existing WC existing injury/condition?

    Are you basing the PEC on the new medical plans that the President signed because PEC treatment can't be
    denied?

    In NYS if someone is injured, and another employer hires this person with the knowledge of the previous injury, the new employers WC IC wouldn't be responsible for the past injury if it acted up again but the NYSSF would cover the costs associated. The NYSSF is governed by NYS to encourage employers to hire a previously injured individual, and is funded by every WC insurance companies.

    I don't know if this of any assistance but throwing this out to see if it is helpful.
    Good luck!
    Knowledge is a beneficial tool for the injured worker!

  10. #10
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Switching to Health Insurance to Have Surgery Done

    May I also say that I did some research at the law library last year, and found a case in CA. that was settled with a C/R . The IW thought his GHP would cover this injury and when he found out the would not, he returned the money, the judge set the C/R aside and I assume he got medical from the ER/IC. So, that seems to contradict what my AA said, although each case may be different...I don't know..
    Don't know the case you refer to...I know there was a case where the GHP came after an IW who used the coverage for work injury treatment, and SUED him in court. Threatened to take his house away if there was no restitution.
    You cannot use the GHP. Read the EOC/Evidence Of Coverage... industrial injury/illness is expressly exempt.

    I said before, there is no "pre existing'' issue in WC... WC is about liability, IW/we are not liabile, the ER is. That is the reason GHP doesn't cover.
    If you take the money, let another party pay, you can be charged with attempt to defraud the IC, or Medicare. And they will, and do come after those cases.

    Medicare is an issued in ALL claims that include medical care. WC, PI anything. Congress changed the law... MSPA/Medicare Secondary Payor Act, and SCIFF (or whatever the acronym is) now requires reporting of any claim that changes/closes medical care. Failure to report, or take Medicare into consideration can result in penalties up to $1000/DAY, plus THREE TIMES any amount Medicare may have paid. That includes the IW.
    Ask your AA just how many of these claims or PI cases he's settled, and get the malpractice carrier info too.
    There is a chance that surgical intervention will not be a real option for years down the line, but I don't really know that for certain...
    IC's don't pay money for "just in case" treatment. If you require additional medical care...DO NOT close the medical in your claim. There is nothing confusing about that. You will not be paid enough money to cover even a pre op visit. You will be charged the 'usual and customary' fees. IE...my last surgery was billed at appx $325K... the IC paid $80. They enjoy contracted fees, and the OMFS/Official Medical Fee Schedule. IW don't.
    yet the IC seems to decline other recommended non surgical treatments.
    Why?...why should they?... you have already been provided treatment, supposedly conservative, as surgery is generally the last option. Once that is exhausted, surgery may be recommeded... if you decline any treatment recommeded that will "cure or relieve from the effects of your injury", you are automaticlally MMI, rated and move on. When you are holding liability for an injury/illness... take all the time you want. Treat til you just can't afford any more. No one can force you to have any surgery...but in WC, the ER/IC isn't liable while you hang around to try everything else, and make up your mind.
    WC is about treat, recover, and get back to work. If you don't like those options... that of course is your choice.

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