Montana Worker's Compensation - Help For Injured Montana Workers

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  1. #1
    Join Date
    Oct 2011
    Posts
    4

    Default Claim of Pre-Existing Condition

    Just found this website and thought I would give it a try. About a year ago at work I hyper extended my knee causing a tear of the meniscus. Surgery was done and it was found out during the meniscus removal that I also have two grade four areas that are being considered a pre-existing condition and not related to the meniscus tear. I am back at work and still in a lot of discomfort from the two grade four areas. My Orthopedic Surgeon said I only had one other option for the discomfort and that would be a complete knee replacement. Work Comp sent me to a IME and it was determined their that Work Comp would not be responsible for the knee replacement as it was pre-existing. My question is, never in my life have I had any trouble with my knees until I hyper extended it and had to have surgery. My questions are:
    What are my options and do I have any?
    Is their such a thing in Montana of a pre-exisitng condition not being covered after being found from some other type of accident to the same area, as in my case the knee?
    I can't afford to be out of work, terminated from work because I can't do the job, and it wouldn't be good if I was transferred to some job that was of the nature that the company was just trying to get me to quit, I like the Dept. I work in?
    I am cautious just in thought of going and seeing an attorney and the ramifications that could come of that.
    Greatly appreciate any thoughts or assistance.
    Wes

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

    Default Re: Claim of Pre-Existing Condition

    Is their such a thing in Montana of a pre-exisitng condition not being covered after being found from some other type of accident to the same area, as in my case the knee?
    As a rule...generally speaking.. aggreviation to a prior injury, or pre existing condition is a compensable claim. Even if a underlying condition such as diabities required medical care to stablize, that would be a liability of the ER/IC.
    It wouldn't be out of the question for you to not expereince any symptom of the underlying condition...your ER takes you "as is" on hire, they can't exempt a medical condition as pre existing on hire. Did you ever have a accident/injury to your knee?
    I can't afford to be out of work, terminated from work because I can't do the job, and it wouldn't be good if I was transferred to some job that was of the nature that the company was just trying to get me to quit, I like the Dept. I work in?
    There could be any number of reasons you may at some time have to face a change in your job, not necessarily due to a work injury. If you are given permenant restrictions due to your knee injury, your ER will make every attempt to place you in a job that fits what you can do. If not, you may be eligible for additional benefits.
    I am cautious just in thought of going and seeing an attorney and the ramifications that could come of that.
    It does't cost anything to talk to an attorney. Your ER wouldn't know unless you sign a retainer agreement.
    Right now however, you have a IME and denial. There are time sensitive issues here you may not be aware of. IF you miss filing a timely dispute, the claim will be closed and you'll be on your own...out of pocket, as your own health ins won't cover the treatment cost of a work related injury.

    You NEED to talk to an attorney specific to WC. Or you could contact a claims specialist at the WC commission...http://erd.dli.mt.gov/workers-comp-c...ance-unit.html Please don't wait on this...

  3. #3
    Join Date
    Oct 2011
    Posts
    4

    Default Re: Claim of Pre-Existing Condition

    Thank you so much for your assistance BvIA, nice to be able to share some of this and get others assistance. You asked, Did I ever have a accident/injury to my knee? I have never had an issue with either of my knees throughout my life of 52 years, I have been very active my life with hiking, mountain biking, skiing, snowboarding, etc. Had to keep up with my two sons! I did receive a very small one time check, like 1100.00, from Montana State Fund for what they felt was the percentage of my disability. I am not in my office at the moment to give you the exact amounts or what they called the compensation. I told them I feel their is no amount of compensation when you are unable to get down on the floor with your grand-daughters or play a little 2 on 2 basketball with your sons, my life has truly changed. From your response and from what I have read, is there really not something called a pre-exisiting condition or one that can be used as it would relate to my situation?

    I am realizing that some time in my life I may have to face a job change but I would hope that would be able to be my choice. I believe that with surgery I still could do the job I am presently doing and to be honest, I am not much of a desk job person.

    As you suggested, I will contact a claims specialist at the WC commission in Helena, MT first, do I have any concern of them contacting my employer or is a person able to talk with them on a confidential level?

    Again BvIA, greatly appreciate your assistance and any other words of wisdom would be appreciated. Again, never have I had a problem with my knees.

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

    Default Re: Claim of Pre-Existing Condition

    I did receive a very small one time check, like 1100.00, from Montana State Fund for what they felt was the percentage of my disability.
    At some point you were apparently rated for PPD/Permenant Partial Disability by your Dr, or another Dr, that check was for that indemnity you were due.
    I told them I feel their is no amount of compensation when you are unable to get down on the floor with your grand-daughters or play a little 2 on 2 basketball with your sons, my life has truly changed.
    Unfortunately WC does not provide for compensation for the type of losses you describe. You are paid indemnity benefits for your reduced earning capacity, or reduced ability to compete in the open labor market. There is no money for pain/suffering...

    I don't think there is as much issue with 'pre existing' condition as maybe your time sensitive filing for a dispute. You've been paid the indemnity due. You didn't say your date of injury, or what the current status of your claim is.

  5. #5
    Join Date
    Oct 2011
    Posts
    4

    Default Re: Claim of Pre-Existing Condition

    I can't say enough for my appreciation for your help and comments. Both myself and my wife have a few more questions if you wouldn't mind commenting on.

    You asked for my date of injury, it was 10/22/10 and the current status is, in their words, If I disagree with Montana State Fund decision concerning my claim I can notify them in writing, a response would be made by Montana State Fund within 15 days. If I am then not satisfied with their response I can request a non-binding mediation conference. So that is where I am at with my knee. I believe in Montana you have 60 months to address issues with a claim as the only reason I say that is I have another question with a different claim I had one year ago.

    I am able to function with my knee as it is...for a while anyway ....as the Orthopedic Surgeon said, at my age I should hold off as long as possible on the knee replacement. What I am looking for is accountability, I just feel, not having any previous problems or concerns with my knee or knees, is that if Montana State Fund should be responsible for my knee replacement when the time comes, that they are held accountable. That is all I want, what is truly fair and right.

    The other claim I was mentioning was 8/4/2010 for a shoulder impingement and it stated that medical benefits are permanently closed if not addressed or used within 60 months. I am in a job that is very repetitious and I use my shoulders heavily, I received a cortisone shot on 8/20/2010 as the pain and discomfort was not subsiding. The shot helped for about 5 months and then I had to have another shot on 1/19/2011, the Orthopedic Doctor said at that time that he would not give me anymore shots and surgery would be required if I had a re-occurrence of the pain. This same Doctor did a scope on my right shoulder 6 years ago and he said in August of 2010 that it didn't surprise him that my left shoulder would need scoping. Well, about a month ago the pain set in and now I am taking a lot of ibuprofen and icing to keep the discomfort at a minimum.

    The questions my wife and I are pondering are:
    How do you address two different claims with my present employer and with Montana State Fund? With the knee and trying to figure out if Montana State Fund should be responsible and if not will our insurance company cover the knee replacement since WC denied me, and with my shoulder now in pain again and possibly or more than likely needing surgery?
    I love my job and what I do, I am concerned that my employer will want to put me in a non-physical job(desk job), my question is, can they do that or do they not have to allow me to try and keep doing my present job?
    I am concerned with just talking to my employer now about my shoulder as in there eyes I am just getting past my knee injury. I am not one to be held back by my physical or medical conditions, after my knee surgery in 2011 I was back to full duty in less than 4 weeks and with my shoulder surgery in 2005 I was back to full duty in a week. Again, I can't afford the time off or being out of a job. So I have a lot of concerns for my families financial well being. It is getting late and I am up at 4:30 a.m. for work BvIA, I know my wife and I will have more questions and wo only hope we can look to you for guidance. I can only say, Thank you so very much.

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

    Default Re: Claim of Pre-Existing Condition

    You asked for my date of injury, it was 10/22/10 and the current status is, in their words, If I disagree with Montana State Fund decision concerning my claim I can notify them in writing, a response would be made by Montana State Fund within 15 days. If I am then not satisfied with their response I can request a non-binding mediation conference. So that is where I am at with my knee. I believe in Montana you have 60 months to address issues with a claim as the only reason I say that is I have another question with a different claim I had one year ago.
    You do NOT have 60 months to dispute this claim.
    Don't make comparisions with a prior claim.
    If you miss the timeframe to dispute... you forfeit that right. The MT State Desicion will stand.
    IMO...you need to consult a WC atty.
    The other claim I was mentioning was 8/4/2010 for a shoulder impingement and it stated that medical benefits are permanently closed if not addressed or used within 60 months.
    Probably right. A claim/medical can close 60 months from the last payment of benefits, or medical care.
    How do you address two different claims with my present employer and with Montana State Fund? With the knee and trying to figure out if Montana State Fund should be responsible and if not will our insurance company cover the knee replacement since WC denied me, and with my shoulder now in pain again and possibly or more than likely needing surgery?
    You're still trying to compare the two claims...they are not related.
    I love my job and what I do, I am concerned that my employer will want to put me in a non-physical job(desk job), my question is, can they do that or do they not have to allow me to try and keep doing my present job?
    If you have permenant restrcitions due to any injury, your ER would have to address the ability to provide a job for you that fits...you should not be performing any job outside those restrictions. Yes...they can do that. No, ER is not required to let you do what you can...you cannot legislate what any ER does in defining a job description.
    I am concerned with just talking to my employer now about my shoulder as in there eyes I am just getting past my knee injury. I am not one to be held back by my physical or medical conditions, after my knee surgery in 2011 I was back to full duty in less than 4 weeks and with my shoulder surgery in 2005 I was back to full duty in a week. Again, I can't afford the time off or being out of a job. So I have a lot of concerns for my families financial well being.
    Doesn't matter about your ER's ''eyes" what you can/can't do due to a claimed injury, and within a Dr restrictions is a medical determination...not the ER.
    There are many situations in life that may change the way you view things...including injury at home, or work. In a work injury, you are entitled to specific benefits as defined by law, that includes medical care, and temporary indemnity while you treat/recover. If there are premenant impairment/disabilty that limit your earning capacity, you are entitled to PPD indemnity benefits, as defined by statute. If you cannot return to your pre injury job function, you may be eligible for VR services to find a new job. That's the way WC works.
    know my wife and I will have more questions and wo only hope we can look to you for guidance.
    I appreciate you thanks... but do not substitute any message board for legal advice, or guidance...it's not here. You need to have a talk with a competant WC attorney to determine your rights and responsibilities regarding these claims.
    If you don't... you are at risk of being railroaded and possibly screwed over... that too is the way WC works sometimes. Your ER/IC continues to be liable for your shoulder injury, and knee. If you require a TKR/Total Knee Replacement... your own health coverage wll not pay.

  7. #7
    Join Date
    Oct 2011
    Posts
    4

    Default Re: Claim of Pre-Existing Condition

    Made contact with a claims specialist at the WC commission today, she truly understood my frustration and feelings about the pre-exisiting condition. She stated that by the law, the insurer, Montana State Fund has abided by all laws and policies of Workman's Comp. With my knee, I injured it on a table causing a tear of the meniscus, surgery repaired the damage of the meniscus tear. The claims specialists stated that this is all they are responsible for and that their are no gray areas. The Orthopedic Surgeon as well as the IME Dr. both stated that I had a pre-exisiting condition and that more than likely would not be covered by Work Comp. I do not have any permenant restrcitions due to my knee or shoulder. My knee gets fairly stiff by the end of the day as my job consists of being on my feet all day. And my shoulder I will be mentioning to my supervisor next week and going in to see a Dr. The one option I have been given at this time by the claim specialists is mediation. It is done as a phone conference with a third party mediator. You can have an attorney if one wants but the claims specialists says very rarely does anyone have an attorney. If after the mediation, I don't like the outcome, then I can request a Work Comp court hearing. That is kind of it in a nutshell, just wanted to let you know where I stood at the moment. I will also be contacting a Work Comp attorney next week and talking with him about the pre-exisiting condition and see what his take is.

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