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  1. #1
    warrior Guest

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    Hi everyone,,I need some guidance...My condition is adhesive capalitis/bursitis of shoulder...home therapy has failed and what little sporadic p/t has failed to improve my condition...Insurance is denying all treatment including orthrosopic surgery and manipulation...EVERYTHING!! I will loose some works rights after 1 year.(Sep) ..My wife is badly ill . I need my job back with my health benefits for her..... I want my job back!! I want to be whole again...expedited hearing for surgery not till July or so ....THIS SYSTEM SUCKS!! They are playing with my life!!!And my wife's!! What should I do?? Give up and admit defeat and take the C/R.Work with one arm if doc allows me to??..Qme upcoming soon and depo also...What should I do.. please help...

  2. #2
    maria Guest

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    Can you get the treatment through your private health insurance?

    They may be able to give you the treatment, and then file a lien in your WC case. Talk to your attorney, or better yet your family doctor.

  3. #3
    Join Date
    Nov 1971
    Posts
    177

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    My health insurance would pay for my surgery, and the hospital has to accept it. But finding a doctor to perform it is another thing. If WC ultimately has to pay, the doctor will be forced to pay back your private ins. co. and take the WC rate. They do not want to take that risk. And it is legal! Although as a nurse I'd say it's unethical and immoral to deny care to someone who needs it because they happened to be hurt on the job.

    The problem with giving up your case, or any part of it, i.e., saying that WC isn't responsible for your surgery, is that then your health ins. can deny payment because you voluntarily gave up an alternate payment source. And your benefits will get cut off. And you can forget about any settlement.

    I've just been through this thought process myself. I see no way to go except to see it through to the end. Some days I don't know if I can do it.

    Hopefully you are seeing some doctor on a regular basis; have them send you to a pain clinic. Won't help re: working, but this 24/7 pain has a horrible effect on an individual. I know, I'm thinking of going on fentanyl patches at the suggestion of my doctor, who feels it's better than percocet over the long term; and it will be a long time before I can get out of this mess. Yes, it SUCKS big time. That's why we've got to get made and active and call, call, call. Nothing will change if we don't make it happen.

  4. #4
    ben Guest

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    One reason that we are in such a mess is because people crossed the lines and used their private health care coverage instead of workers compensation. As much as we are not happy with HMO's, why should they have to pay for the care of work related injuries that should be paid for by the carriers! I can't blame them. Would you want to pay for a bill that was not really yours? Injured workers are screwed now and we carry on about this without thinking of how we got there. Get a lawyer. A lien on your case won't help you out in the long run. Fight for your care though the carrier and make your voice heard whenever you have the opportunity to do so.

  5. #5
    warrior Guest

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    Hey Been There.. Only one thing ..I agree it is probably unfair to HMO's to use them for WCI,...But, you can't sue them for delaying surgery,, pain and suffering..etc. Abviously,,the IC are playing a very methodical game of delay until you give up and work hurt...For the record , I wasn't even going to obtain a lawyer until the IC suggested I do after we got into a tiff over why they would'nt authorize p/t and I went over nurse case mgr.s head...

  6. #6
    maria Guest

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    My position is, and I have seen it done many many times, I pay for my private health insurance. If WC is denying the treatment, I have a right to get it through my private insurance. Most health insurance carriers, or at least mine, has you fill out the lien forms indicating this is WC, and they then pursue their liens. You are not giving up any rights to WC by getting care through your private insurance. IN CA it's call self procured and is addressed by the Labor Code and case law with great detail of how the private insurance can recover their money.

    My private insurance, along with me, then has a right to pursue the WC carrier by proving that the treatment was necessary for the work related injury.

    Especially with something like adhesive capsulitis, which gets worse without treatment.

  7. #7
    1 Guest

    Default

    My wife is badly ill . I need my job back with my health benefits for her..... I want my job back!!


    Unless the other spouse is working and has a insurance plan through work it's hard to stay out on W/C to the point where your health insurance expires. In this case the man's wife is badly ill and being without insurance is not a option.


    If you wifes illness is long term, she might apply for SSDI.

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