Claim Denied Even Though Worker's Comp Doctor Says Injury Was Job-Related

[Dintyjo]

My workers compensation claim was made in the State of: North Carolina

Hello all,

On March 1, I fell at work and broke 3 ribs. Immediately after I began to feel symptoms of a hiatal hernia I had had surgically repaired over 4 years ago. Until the accident I was fine. Well every step with the insurance company has been a battle but the surgeon they chose and sent me to said that the reinjury of the hernia was more likely than not caused by the rib accident. I just received notice from my insurance company that they are denying my claim and their only reasons were two words Hiatal Hernia.

How can they do that, if their chosen Dr. said the hiatal reinjury was most likely caused the accident? My understanding is that in the state of NC the cannot deny a claim because of a pre-existing condition if it was aggravated by the injury. They can check all my medical records and see that since I had the surgery 4 years ago I have not needed medication or treatment in anyway for the hernia . Every Dr. I have seen I have told about the accident and my recurrent symptoms immediately following the surgery.

I have hired a lawyer but of course I just got this denial and he is gone for the weekend so I will be worrying for the next two days. I am supposed to get an endoscopy done next week to see if surgery is feasible and now they won't pay for it and I can't afford the co-pay from my private insurance. Is this just one of their tactics?

Any words of encouragement would be most welcome.

[.SH]

you might get some help here
http://www.patientadvocate.org/help.php

[Q-man]

My workers compensation claim was made in the State of: North Carolina

Hello all,

On March 1, I fell at work and broke 3 ribs. Immediately after I began to feel symptoms of a hiatal hernia I had had surgically repaired over 4 years ago. Until the accident I was fine. Well every step with the insurance company has been a battle but the surgeon they chose and sent me to said that the re injury of the hernia was more likely than not caused by the rib accident. I just received notice from my insurance company that they are denying my claim and their only reasons were two words Hiatal Hernia.

How can they do that, if their chosen Dr. said the hiatal reinjury was most likely caused the accident? My understanding is that in the state of NC the cannot deny a claim because of a pre-existing condition if it was aggravated by the injury. They can check all my medical records and see that since I had the surgery 4 years ago I have not needed medication or treatment in anyway for the hernia . Every Dr. I have seen I have told about the accident and my recurrent symptoms immediately following the surgery.

I have hired a lawyer but of course I just got this denial and he is gone for the weekend so I will be worrying for the next two days. I am supposed to get an endoscopy done next week to see if surgery is feasible and now they won't pay for it and I can't afford the co-pay from my private insurance. Is this just one of their tactics?

Any words of encouragement would be most welcome.

Welcome to comp. Yes, it is one of the tactics. You need to have this injury established and your attorney will be able to explain the process and guide you through the process of whether or not you can have medical treatment and when and how it will be paid for. THE ic just wants to frustrate you so you'll give up!

[explorereb96]

This re injury is called a compensable consequence injury. The IC is denying because, well, they can. That doesn't mean that it is the last word on the subject. Your AA will have to file a Petition to add this new injury. You may need more than one physician's medical opinion on this. They may send you for an IME (yeah right,,, independent uh huh) before the ALJ hears the petition. This IME more than likely will side with the IC. But that still is not the end of it. The ALJ will side with the Dr. that gives the strongest argument for or against it being added and that it is causally related to your original work related injury.

[Dintyjo]

Thanks exploreb96,

They already sent me to their chosen Dr. who said it was related but I know for a fact that Dr. is not on their payroll. I would think it would be hard for them to make that case since their first Dr. said it was caused by the accident. Even if they send me to another so called "independent" I am sure I can find several of my own who say it was since it so clearly was the cause. I already have spoken to two other surgeons who say a blow hard enough to break 3 ribs is hard enough to disturb a prior surgery.

I saw that my lawyer emailed their lawyer over the weekend asking him what was going on with the denial. It really makes no sense because they agreed to transfer my care (after a month and my lawyer had to make a motion to the courts) to a surgeon who can treat my hernia. The hernia that they are now denying. From the email it looks like their lawyer was unaware they denied and he is following up with them unless he is playing games which of course I know is entirely possible. Ughhhhh as if feeling bad isn't bad enough. Now my employer is going to expect me back at work, workmans comp checks will stop and I am responsible for thousands of dollars of medical bills. I know I need to be patient and let my lawyer do his job but the anxiety and frustration is killing me.

I know there are people out there who scam the system but I am sure the overwhelming amount have legitimate claims and are being treated like criminals. I am so glad I found this forum where I can vent to people who can relate.

[BvIA]

How can they do that, if their chosen Dr. said the hiatal reinjury was most likely caused the accident?

You are tossing quesitons in the air here... no one can answer "how can they?"...
It's called litigating a claim... you go to court. You do go "doctor shopping" to find anothe IME to agree with you.
Wait and let your attorney do his job...

[SteelMagnolia]

Dintyjo I know it is EXTREMELY hard to be patient when you are hurting and need a procedure. However, you are going to have to be just that, patient, while your attorney gets this worked out for you. I know that is tough to do but as the others have told you YES this is the way WC works and IF the IC thinks they can save a buck they will try. Let your attorney do what he is paid to do. It very well could take a good bit of time but in the end you WILL prevail. Even IF it takes a WC judge to order them to pay. In the mean time IF you are in such a state that you just can not tolerate the pain from the hernia repair displacement you can always uses your regular health insurance and have them put a lien on the WC IC to reimburse them once a judge orders them to pay for the repair. Talk to your attorney about this and I will be VERY surprised IF he does not tell you the same.

[Q-man]

Once the case is established and the IC starts paying the bills, over due or current, the system will start working more swiftly in your favor. Its a waiting game that the IC plays trying to make you get so frustrated that you'll quit and walk away, saving the IC $$.

[Dintyjo]

Just an update in case anyone is interested. The IC has now filed a form 24 and stopped my paychecks and Rx coverage. My lawyer says that is illegal to do before the Industrial Trade Commission makes a ruling but they did it anyway. Their lawyer told my lawyer their in house council did this without his knowledge and his hands are tied. Of course we are appealing but in the meantime no $$$$. They make no sense denying the hernia since they already approved my transfer of care to a surgeon and I have 3 opinions including their Dr's that the injury caused my hernia to come back so my lawyer feels very confident but you never know.

[complwyr]

Your lawyer can fight the Form 24 procedure by filing a response and doing a telephonic hearing. They are not allowed to stop your checks without an Order from the Industrial Commission allowing them to do so. If you win the Form 24 and they don't restart, then your lawyer will have to take another action to get the checks restarted.

They can deny a claim all they want; your remedy is to have your lawyer file a Form 33 Request for Hearing and go forward with litigation. That is what the IC system was created for--to litigate disputes and administer claims that are accepted. It sounds like you have pretty good medical evidence, so you are simply dealing with bad faith or incompetence on the part of the insurance carrier. Both are common in my experience.

Good luck. BB