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  1. #1
    Join Date
    Sep 2008

    Default What to Do After IC Denies Claim After IME Report

    IC is denying my claim based on their "Independant Medical Examiner"'s review. I have a copy of this review and there are several dicrepancies between what i told him and what he wrote down (my wife was present and they state she was in this review - will that be helpful if this goes to court?) also he is trying to say that my injury is a manifestation of a preexisting condition which even though it is nearly identical to the injuries in 2005 and 2007 that the IC paid for, that this is somehow related to an injury prior to 2005 which is quite dissimilar in pain and area of the body (which was also work related but could not be proven) also states i have had "severe" back problems on a yearly basis (due to me seeing a chiropractor for regular maintainance - for injuries sustained due to my employment) however this is somewhat false and/or greatly exaggerated, i assume for the benefit of IC to deny the claim. Prior to my employment with this company my medical history consisted of routine check-ups, immunizations. other than that the only medical attention i recieved was 7 stiches for a cut on my head in 1981 when i was 4. every other medical condition started over 1 year after the start of my employment with this company.

    the IC says i am able to contest this decsion if i feel it is inaccurate. i have called to get the forms to start this process and would like to know what other information ( i.e. doctor notes, medical records ) i will need to support my claim that this is related to the 2005 and 2007 injuries.

    i have talked to two attorneys, one said they dont take cases looking for coverage of medical bills only, the other stated i dont need an attorney present for the hearing but if they determine i need surgery or other treatment i should contact him back at that time.

    looking for some pointers as to what to expect, what to bring to the hearing as i am sure the IC is well versed in these proceedings and will try to take advantage of my inexperience.
    Last edited by stimp77; 01-09-2009 at 11:19 AM.

  2. #2
    Join Date
    Feb 2007

    Default Re: What to Do After IC Denies Claim After IME Report

    As everything in WC is based on medical evidence, and the reports of your treating physican, those reports are what you need to prove up your contention that you have a 'work related/industrial injury'.

    If the descrepencies in the IME report can be refuted by your PTP, that would go a long way in the hearing.

    Medical treatment in WC is not subject to 'apportionment' as any permenant impairment would be.
    Where there is an industrial injury, and you file a claim for benefits under the ER's WC plan, even if this is an aggreviation of a pre exsisting condition/injury, you are still entitled to treatment at the expense of the ER/IC.

    What Happens If My Claim is Denied?
    If your claim is denied, either in part or in full, and you believe that you should receive further benefits, your dispute may be handled through a formal hearing or through an informal alternative dispute resolution process.
    Here for more...
    What Happens at a Workerís Compensation Hearing?A hearing may be necessary to resolve a disputed claim. Most hearings are set after an employee, surviving spouse or dependant files an application for hearing (WKC-7). This form can be obtained from the Worker's Compensation Division. Some hearings are also scheduled on the Divisionís own motion in situations where there is reason to believe payment of compensation has not been made. Here for more on hearings...
    And here for additional FAQ's on the WC system in Wisconsin...

    As your doctor is saying 'yes' to the compensability of your injury, and the ER/IC IME is saying 'no', you may be entitled to a 'tiebreaker' evaluation...
    Information on tiebreakers is here...
    Tiebreaker Medical Examinations - Basic Facts

    The department may order a tiebreaker medical examination
    The department will only appoint a tiebreaker doctor if an insurer concedes liability for the injury, but suspends an injured worker's temporary disability benefits or refuses to pay for further medical treatment because two or more doctors disagree about:

    The extent of an injured employee's temporary disability;
    The end of an injured employee's healing period;
    An employee's ability to return to work at suitable available employment; or
    The necessity for further treatment or a particular type of treatment.
    Anyone may request a tiebreaker examination
    Anyone may request that the department order a tiebreaker exam--an injured employee, a family member or friend, an attorney or physician, an insurer or employer. However, generally, the department will not order a tiebreaker exam without the injured employee's consent.

    follow the link above for additional information.

  3. #3
    Join Date
    Jul 2008

    Default Re: What to Do After IC Denies Claim After IME Report

    Just so you are aware, the insurance company will have an attorney representing them.

    When you go to a hearing, you'll need all your medical records. I would also get an opinion from your treating doctor in writing that states the ongoing symptoms are work related and why. Maybe a job description that proves how heavy the job is.

    Did you see any other doctor than a chiropractor? Chiro's only help so much. If you have re-occurring problems, see a medical doctor and get into some strengthening and therapy.

  4. #4
    Join Date
    Sep 2008

    Default Re: What to Do After IC Denies Claim After IME Report

    thaks for the info, just a couple more questions

    what does ER stand for when satated "the ER's IC"

    seeing as the IC had me see an ortho surgen for the IME is his opinion going to hold more weight than a primary care physician, and if so should i have both the primary physician's opinion and have him refer me to an ortho for an evlauation and opinion before the hearing?

    in a physical exam the IME wrote down "with hip evaluation he ambulates with a normal gait" does limping contstitue a "normal gait" as the pain was causing me to limp quite noticably. also he asked me to walk on my toes and then again on my heels, it was painful and could bearly get either one off the ground, he states that i was able to do this but did not mention i told him it caused pain and could bearly do it. (even my wife noticed that i was having trouble and again the IME states she was present, will this be helpful?)

    most of the discrepancies are where the IME was getting verbal background from me, i saw him writting stuff down while i was talking and i assume it was what i was telling him. some of these are refuted by him in his listing of actual medical records later in his own report. one small example was he was told i would lift 43 lb. bottles an avg of 1600 a day which came to about 70,000 lbs. he wrote i lifted between 16 and 100 bottles a day (and no where mentioned the 70,000 lbs.) would it be possible this was intentional to try and discredit me or to make claim that i wasnt lifting enough weight to cause injury, or could it be likely he was not really listening to me and just going thru the motions with intent to deny the claim regardless?

    for the 2 WC back injuries he listed all the resulting treatments, he also listed my hernia surgery (after 2nd WC back injury) and specifically pointed out there was no mention of back injury in the patient history taken for the pre-op. the other thing he put in was for my WC wrist problems 2 years prior to first WC back injury, but only listed 1 doctor note and an EMG that stated that i did not have carpal tunnel. (the doctor note is probably the one that all but states that the problem is in my head because the only thing it could possibly be what the only thing he tested for) turns out it was tendonitis from repetative stress and this diagnosis and following therapy were not listed in the IME report. would this also be intentional to support the IME findings?

  5. #5
    Join Date
    Jun 2008

    Default Re: What to Do After IC Denies Claim After IME Report

    First ER is employer. And yes everything the IME does is intentional. They are paid by the insurance company and if they rule on your behalf how many IME do you think the would get?

    What I would recomend is you have the IME's report so have you doctor write a rebutal and take it with you to your hearing...

    As for the lawyers you are better off with the 2 you mentioned not representing you... Call around and see if you can find one you are comfortable with.

    Also most states allow for aggrivation of pre-existing injuries, so you may need to check out that route.

  6. #6
    Join Date
    Jul 2008

    Default Re: What to Do After IC Denies Claim After IME Report

    More than likely the ortho will hold more weight than your primary care physicians. You are better off getting an ortho opinion prior to going to hearing.
    Another thing, different IME doctors hold more than weight then others in front of judges. It all depend on how reputable the doctor is as to if the judge will believe what's in the report or not. Not all IME doc's are bad as some might say in the answers you see. It appears you may have gotten a bad one though.

  7. #7
    Join Date
    Mar 2008

    Default Re: What to Do After IC Denies Claim After IME Report

    pitchin21 you are wrong. Most insurance for work comp use the same IME and the arbitrators know which ones are being paid by the insurance companies because their reports are always pretty much the same. Insurance companies think that they are sneeky in doing this but the are not. My last IME I went to did not touch me, really even didn't look at me or anything and said there was nothing wrong with me i needed to exercise more (like 2 years of exercise with PT 3 times a week was nothing). If you have a nurse case manager going with you to appointments watch them too mine lied sooooooo much on her reports saying that i never asked questions of the doctor never asked to return to work which was really funny because she was never in the room with me to know what i asked him. Why would i ask her when my doctor is the one with the MD license not her. You are so much better doing all this with an attorney. Seriously because they have more knowledge of their sneeky tricks to put them on the spot. You want to have one to fight for you and get you what you need. Plus they can get more files quicker and more admissable in court cause they get different papers then what we would get. Good luck and let us know what happens. Shop around for an attorney!

  8. #8
    Join Date
    Sep 2008

    Default Re: What to Do After IC Denies Claim After IME Report

    i have gone back to my doctor to get a "doctor note in lieu of testimony" thing and brought some personal records with to show how much my workload increased shortly before my injury (we had discussed these records at my initial injury visit but he never mentioned it in his notes nor had he specificaly state the he felt the injury was work related which was why i had to get the testimony thing) he told me that i should definitly keep them and bring them to the hearing.

    when i got home i checked the mail and got a letter from the IC with a copy of a record used by the IME to support the IC's claim to deny benefits. this record was an inter office memo between 2 IC employees stating that i had 2 prior back injuries (did not state location or severity just stated back injuries) and another line state the one employee asked my doctor if it was felt my pre injry status was lees than 100% but does not specifically state that the doctor felt i was less than 100% or what % he felt i was pre injury.

    the IME summarized the note in his report that i had severe low back injuries and that it was felt i was less than 100%

    between my copies of the doctor notes and the memo there is no mention of severe low back pain, so this is an outright lie i can prove. the less than 100% may be a bit trickier to prove but i think i can show documentation to at least indicate this is inaccurate as well.

    i have a lot of other documantation gathered up to poke holes in the IME report but this just made my day an easily proveable outright lie ( he outright lied about my "walks with a normal gait" when i came in to his evaluation with a moderate limp, but it's mine, and my wife's word against his.

    i am looking forward to the hearing now

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