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  1. #1
    Join Date
    Nov 2009
    Posts
    1

    Smile Refusing L&I Surgery

    I was injured on the job and am currently receiving time loss benefits.
    I have and fully detached subscapularis tendon, SLAP tear, and damage to the bicep pully. The 2 L and I surgeons wanted to drill a hole through the bone and tie the tendon down while also doing a tenodesis (cut the bicep tendon and move it down to the humerus). L and I pays about $3900 for both proceedures.
    I want them to repair the bicep pulley and reattach the tendon using bio-absorbable sutures and anchors because for religeous and personal reasons I do not want the nylon and metal left in my body. These are newer techniques that take almost twice as long to do and have more expensive supplies. I have two out of state surgeon who will do this but they will not take L and I as they want over $15,000.
    If I do not accept the L and I surgeons surgery recomendations can L and I - 1) stop my time loss payments; 2) deny retraining; 3) deny PPD benefits (without the surgery I will have about a 30% loss of use); and 4) close my case?

  2. #2
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    17,941

    Default Re: Refusing L and I Surgery

    WC is geared to treat, recover, and return you to gainful employement as soon as practical. If you decline the treatment as recommended by your treating physicans... you could see your benefits stopped.

    The concerns and thought process you have are valid, but may need to be litigated, a judge order the treatment you are seeking.

    Comp treatment is not like that which you might see under your own health coverage... when you are paying the bills, you can have pretty much any treatement your IC is willing to authroize.

    WC treatement doesn't usually authorize treatment outside the usual and customary. Nor pay wage loss while you consider something else.

    Functional restoration, and a return to gainful employment... whether that is pre injury ER or job...doesnt' matter.

    IF you were to settle out the claim for a lump sum including medical...you will not receive enough money to seek the treatment you are describing.
    I want them to repair the bicep pulley and reattach the tendon using bio-absorbable sutures and anchors because for religeous and personal reasons I do not want the nylon and metal left in my body.
    Do you have a Doctor describing that approach as medically necessary, and reasonable for your injury ?
    Or, is this something you have heard about, and researched on the internet...? You need medical evidence and reasoned opinion to get this through a hearing/mediation process.
    I have two out of state surgeon who will do this but they will not take L and I as they want over $15,000.
    Your ER/IC isn't necessarily liable for treatment that is outside the minimum necessary under the laws governing comp. Even in mediation you might get the 3900 from the carrier, you pay the balance out of pocket... only a judge will determine that.
    If I do not accept the L and I surgeons surgery recomendations can L and I - 1) stop my time loss payments; 2) deny retraining; 3) deny PPD benefits (without the surgery I will have about a 30% loss of use); and 4) close my case
    Yes, yes, yes... until you have the treatment as recommended medically necessary, and reasonable on an industrial basis.

    The problem with going outside the treatment guidelines as your doctors are recommending is what if the procedure you want is not successful...and additional surgeries are necessary... and again...and possibly again? The ER/IC is not going to pay triple fees.

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