Worker's Comp Denial, Mechanism of Injury 'Not Substantiated by MRI'

[NotHappy]

My claim was made in the state of : Texas.

First off, let me say hello to everyone and let you all know how happy I am to have found this site! Sorry for the "book" I am about to write, but it is a complicated situation that I'm, unfortunately, having to go through.

Back in 2008 I suffered a fall, while on duty, which resulted in a double year in my meniscus. Had surgery to repair the tear in 2009 and after some rehab, went back to work. A couple months later injured the same knee, from a wet bathroom floor, which resulted in a sprained MCL. In both cases everything was covered under Workman's Comp and I received TIB's.

On 3/17/2012, I was injured on the job. I was forced to fill out the injury report and claim form, before being allowed to get medical treatment. I went to my employers doctor, the first chance I got. By choice. They put me in a knee brace and on crutches, set restrictions and diagnosed me with a sprained LCL and patellar tendonitis. I didn't hear from my adjuster or employer for several days until the day I was scheduled for my followup with the treating doctor. That was on the 23rd of March. I gave my recorded statement to the adjuster, over the phone and was told that she was going to call my treating doctor and authorize an MRI. That was done and after the appointment I had the same restrictions. The MRI was done the following day, 24th. When the results came back I was told them by my treating doctor. He stated that in addition to the other injuries I had, that there was no mention of my LCL in the report. On the 3rd of April I received a call from my lady in payroll asking me if I had spoke with my adjuster lately. I said no, why? She said I needed to call them because they had denied my entire claim. I called and my adjuster states the reason for my denial was, "the mechanism of injury wasn't substantiated by the MRI findings and that the MRI report showed that I have a degenerative medial meniscus and that they consider that to be a natural disease of life". Interesting thing considering there was no mention of my LCL anywhere in that report!

I never received any TIB's, at any point during this whole ordeal. I had been approved for 6 sessions of physical therapy as of the 29th of March, but the denial was on the 30th of March. Kinda convenient, isn't it? I have contacted the state and a lawyer on the matter. I am still employed, but who knows for how long. My payroll department sent me FML paperwork and asked me when could I get a full duty release. How am I supposed to do this when #1 I am unable to work at this time, #2 have no TIB's coming in to afford the doctors visit to get the stupid release, which he wouldn't give me anyhow. Btw, before getting denied I was told in writing that my employer wouldn't be able to accommodate my restrictions.

I have been studying everything to do with the TWCC Laws and from what I understand, if my employer is unable to accommodate my restrictions then I'm entitled to TIB's. Never received any....from anyone.

Found out today from my Attorney that my employer is self insured but they used a third party administrator. So he said that actually works out in my favor.

I really hope these people rote in hell for this! I just had twins on the 4th and with no money coming in I'm being forced to pawn, sell and borrow to pay bills. Much less anything else. I am married have the twins as well as a 10 year old and a 7 year old.

Sorry for the long rant, but maybe there's something I'm missing here, ghat maybe one of you guys could point out for me.

[BvIA]

When there is a denied claim...you go to DDD. The CA doesn't make medical determinations...and a preexisting condition, degenerative anything... can be aggreviated by work injury, and is generally compensable.
Let your atty handle this... no one on a message board should second guess what your atty may have in mind. It may take the DD/Designated Dr, and/or a hearing in comp court to get the benefits/TIB's ordered.

[NotHappy]

So....what am I to do in the meantime? I've got 4 beautiful children, now, that have to eat just like my wife and I. I have almost had my electricity turned off because we almost couldn't pay the bill. These people (IC) don't care about you or your family. They only care about saving money and trying to get away with not providing benefits. Heck, even my employer was supposed to pay my TIB's while the IC was conducting their investigation. I was out almost 2 weeks before a decision was made. Even my Attorney was like, "well we can ask for the TIB's you should've gotten after the denial, but they don't allow us to ask for the one's you received up until the denial." When I told him I never got anything he was, well, shocked and pissed. Lol. It does make me feel a little better knowing that I'm not the only person, besides my family, that realized that this whole thing is bullshit*t.

Thanks again for your guys' thoughts and prayers. I just want this all to be over with. I'm so tired of the games and the unjust denials that they're giving me. I can't wait until someone, with the authority to do so, orders these scumbags to fix the crap they've been doing to me and my family!

[complwyr]

Make sure your lawyer is moving aggressively on it. And call your state legislators for where you live and complain about it so they will know what real people go through with this horrible Texas work comp system that they put in place.

[NotHappy]

I know I'm new to the forum and all, but jeez...lol. I appreciate the opinion I got from the both of you. I hope some others have some more ideas. I'm open to, just about, anything...lol. I am hoping that my lawyer can get me some headway on this matter.

If I were to file a "bad faith" complaint would that help, you think? Or would that just make them want to drag this out even further? I've thought about using an OMBUDSMAN, but I don't know how much I could get. I am hoping that someone, with the authority to do so, grants me my TIB's until I finish getting my knee fixed. That's all I want, as I'm sure that's all everyone wants, while going through this. It totally sucks that it's gonna cost me and arm and a leg to fight this, all the while the ER and IC aren't sweating the cost of the litigation process. How dumb can these people be to think that the litigation costs are gonna be lower than just paying me, both TIB's and my Medical treatments?

[.SH]

not unless you are going to file it on your own. you'll have an impossible job finding an atty to handle a bad faith as it is such a long shot and the damages are generally not enough to cover the fees and expenses.

[NotHappy]

Yes, I was referring to filing it on my own. Unless my Attorney wouldn't mind just adding that to the long list of things that "we've" got this far. All this "denial" crap is new to me. Like I states above, I didn't have any problems with my last two claims. I don't enjoy any of this. What kills me is that because there are people that are dumb enough to actually commit fraud by doing this, hurt everyone else who are having health problems through no fault of their own! I would've never had problems with my knee had my employer kept a safe working environment! Eversince 2008, when I got injured at work I've had nothing but problems with it. Just one thing after another.

My employer is self--insured but has a TPA, so from what I understand it's the TPA's medical people who make the denials. I don't understand how any one with medical training can look at the facts surrounding my case, and honestly deny it. Especially considering in by doing so they're over riding the treating doctor and discrediting him. If my treating doctor states I have a sprained LCL and theirs no mention of my LCL, at all, in the MRI report, which a third party doctor wrote, how can the TPA's doctor look at those two facts and say that the entire claim is denied? Don't they realize that someone, i.e. the radiologist has more than likely falsified the MRI report and that once this goes to court the judge will order my TIB's be paid? Not too mention wasn't it clearly bad faith, on my employers part to not pay me TIB's while the IC was investigating? I understand that after 8 days, the employer is supposed to pay TIB's and cover ALL lost wages from the date of injury until the IC makes a determination? So, along with the action of not allowing me to seek medical treatment before filling out all the paperwork (report of injury and claim form) and denying my TIB's until the IC made the determination, doesn't that make for a solid bad faith case? I know I've got a lot of feelings involved so, I may not be able to look at it objectively, but it sure seems like they have been trying to shaft me from the get go. Am I wrong?

[complwyr]

You are the employee claiming under the employer's insurance, so you are not the insured entity. Therefore "bad faith" does not apply to you. You have no "bad faith" claim to make. Confirm this with your own lawyer, of course.

---------- Post added at 11:20 PM ---------- Previous post was at 11:18 PM ----------

You think a radiologist will jeopardize his multi-million dollar career to "falsify" a MRI report pertaining to you? Really?

Listen, you are in a state in which the criminal justice system sends innocent people to death row. Your state legislature has "reformed" the work comp law every way it can to favor the employer and the insurance adjuster. Texas has one of the worst comp systems in the country for employees, thanks to your conservative legislature. It is hard to get a happy outcome in Texas. Hire the best lawyer you can and encourage him or her to fight for you.

[NotHappy]

You are the employee claiming under the employer's insurance, so you are not the insured entity. Therefore "bad faith" does not apply to you. You have no "bad faith" claim to make. Confirm this with your own lawyer, of course.

---------- Post added at 11:20 PM ---------- Previous post was at 11:18 PM ----------

You think a radiologist will jeopardize his multi-million dollar career to "falsify" a MRI report pertaining to you? Really?

yes, really. Actually it wasn't me that came to that conclusion...it was the state. When I first contact the DOI - Office of Injured Workers, and told them my story they suggested that it sounded to them like the radiologist had falsified the report. Personally, other than some type of "forgetfulness" I couldn't explain why that part was left out of the report. Only thing I could think of was my LCL was left out of the report because the only other thing wrong with my knee is a degenerative meniscus, to which they are denying my claim because of. Staying that it's a natural disease of life and therefore not compensable. Convenient? I think in more ways than one. Look the ER I work has a very corrupt side of doing things. Since we are "the law" it all gets swept under the rug! Fortunately enough, I am not involved in any of that as it is at a pay grade WAY above mine. However, it is there and they know that I'm one of the few that knows so I figure they're just trying to piss me off enough that I just go away. Unfortunately, for them, it's my health that's in question now and I don't mess around with that. Again, sorry for the rant. No, please don't ask, because I'll tell you guys just like the federal governments does....that's classified....well technically with them it's "confidential", but you should know what I mean.

[BvIA]

My employer is self--insured but has a TPA, so from what I understand it's the TPA's medical people who make the denials. I don't understand how any one with medical training can look at the facts surrounding my case, and honestly deny it. Especially considering in by doing so they're over riding the treating doctor and discrediting him. If my treating doctor states I have a sprained LCL and theirs no mention of my LCL, at all, in the MRI report, which a third party doctor wrote, how can the TPA's doctor look at those two facts and say that the entire claim is denied?

It's commonly referred to as "litigation"... either side has the ability to dispute a claim, Dr report.... even DDD opinion. You're not out of the norm here... you go to court and get a WC judge to issue a finding. That's how WC works.