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STD Denial,,,,this is a long post

williamj67wwilliamj67 Posts: 7
edited 06/11/2012 - 8:42 AM in Health Insurance Issues
Ok this may be long. I was injured at work in July 09, I was out of work for 7 weeks then I returned. I started feeling pain again so I went back to the Dr. I got an MRI which I will post the results of further down. Then the Ortho referred me to a surgeon and a pain doc. because of results of MRI. Surgeon found out I have spondlylisthesis(sp) he ordered more x-rays and a CT. I went out of work again for 2 weeks in Dec. then I went back and went out for good 1-27-10. I am in to much pain and I have a VERY physical job. at this point I couldn't hold any job because I can't sit, stand or walk very much. Anyway the surgeon wrote me out of work for 3 months, no light duty or anything, my STD who also runs the WC case says medical dosen't support me being out of work because my gait and range of motion are fine. I also think in mid january I totally blew my disc out and that's why may pain level went through the roof but the Dr.'s didn't do any new physical exams on me. So I call surgeons office today to ask if they can submit more paper work to get STD approved and the dr tells his secretary to tell me that I am fit for light duty next week and to go to work. I was speechless, I have a written note in my hand clearing me until May 8th 2010, is this legal? I've had 3 epidurals, the first 2 gave minimum relief and the 3rd one none at all. I don't know what I need to do, I have an ortho reg. dr, an ortho surgeon and a pain dr. do I need to go to a general practitioner for std approval?
Oh on top of all this, I got a new WC adjuster who won't return phone calls (I have since hired a lawyer) because I am waiting on a second opinion, first surgeon says I need a 3 level fusion. I also researched this surgeon and found out he had a patient die during a routine discectomy, so I bet he is trying to appease WC co. so they keep referring patients to him.
here's my test results.

The doctor only says I have Bulging discs in the mri which was performed 3 months before the C-T scan. In the C-T scan he refers to some discs as herniated.
Both MRI and CAT-SCAN results writen by the same Doctor.
MRI results 11-6-09
T11-T12 There is disc bulging noted. This is imaged only on the sagital plane.
There is deformity of the sac but no deformity of the anterior margin
of the cord is noted.
T12-L1 There is disc desiccation.
L1-L2 No evidence of disc degeneration or herniation. There is no evidence of canal
or foraminal stenosis.
L2-L3 No evidence of disc degeneration or herniation. There is no evidence of canal
or foraminal stenosis.
L3-L4 There is diffuse disc desiccation and diffuse bulging. No herniation or
neural impingment is seen.
L4-L5 There is a right sided broad based disc protusion noted. This causes mild
deformity of the exiting right L-4 nerve root primarily due to foraminal
stenosis. The disc very slightly deforms the anterior margin of the
thecal sac. The left L-4 nerve root exits without impingment.
L5-S1 Disc desiccation and mild narrowing. Very slight asymmetric bulging
on the left. No neural impingment is noted.
Cat-Scan results from 2-9-10
T12-L1 Normal
L1-L2 Normal
L2-L3 Normal
L3-L4 There is disc bulging present which does appear slighly more pronounced on
the left compared to the right. Nerve roots normally.
L4-L5 There is diffuse disc bulging present along with a broad-based right-sided
foraminal disc herniation. It does not distincly displace the exiting right
L4 nerve root although it does extend to the inferior aspect of the nerve
root and may actually impinge the nerve root onto the right pedicle. I do
suspect involvment of the right L5 nerve root. Associated disc bulging is
present. The left L4 nerve root and left portion of the thecal sac appears
unremarkable. There are bilateral Pars defects present at L4. No listhesis
is identified.
L5-S1 There is an asymmetric disc bulge on the left causing mild posterior
displacment of the left S1 nerve root. No central stenosis is noted.
There are no paraspinal soft tissue masses identified. Suspected small bone
island is noted at T12


  • SpineAZSpineAZ WiscPosts: 1,084
    First, call the physician's office that wrote you the note and explain you that you were of the understanding they would support STD. If necessary make an appointment to discuss in person. When I knew things were getting bad I called my surgeon's office and they did say they'd support STD. When I filed my STD claim they sent out an Attending Physician's Statement (APS) for my doctor to complete. I was able to complete it with the assistance of my doctor's medical assistant and sent it in. Under a PM I will send you they type of detail I made sure we provided for STD approval.

    STD is not granted on a physician's note alone. The STD insurance company (or third party administrator if they do it that way) will need to gather medical information and then compare it to the physical requirements of your job. If you go out on STD you either fill out forms or should have a full interview with the insurance company disability staff who will ask extensive questions about all your doctors, your symptoms, what you see as the treatment plan, and what your return to work plans are if any.

    You have to show them that regardless of what you can do there are specific important parts of your job requirements that you can not do. So take a look at the documents I will send you and see if that helps. I used to be in the STD/LTD industry but with an insurance carrier - it sounds like maybe your STD is handled internally?
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • It is Sedgwick, they are contracted by my employer. I did call the surgeon yesterday, that's when the jerk said I should go back to work in 1 week. Apparently he is not going to help write me completely out of work. My dept. doesn't have light duty and to qualify for STD I have to be written completely out of work and the Dr. won't do that but he will put me on light duty. I told him I can't sit, stand and walk for very long. He says "you're not disabled, I have spondylilothesis(sp) too and look at me, I'am working and I'm fine". He says he will fix me right up and I'll go on with my life, never even discussing all the other things in the MRI and CT reports.I also asked him does he do his surgery with the help of a neurosurgeon, he says, nah, those guys just get in my way and slow me down, my wife and I were like "huh"? Jerk. I don't like that guy as you can see. I guess basically I need a new course of action, my PM dr. is very cool and he supports me as best he can but I'm not sure how strong his opinion is taken by STD. I'm waiting on 2 opinion from another surgeon over at Duke or Chapel Hill, can I choose one of them to take over my treatment? The surgeon I have now I wouldn't let him touch my kids "operation" game! Anyway, as you guys can tell I'm a bit pissed, I don't know why he is like this?

    On a side note, I was cutting up a cantelope last night for me and the family, my back started KILLING me, I actually had to stop for a couple mins. Usually I can tough it out and finsh the job but not last night, also I was having all kinds of nerve pain in my legs, like a burning pain. I was also in pain in the morning straightening the kitchen for my wife, it seems like if I stand for very long with my arms extended in front of me I wear out in 5 minutes instead of the usual 20 or 30, weird huh?
    Thanks for the support and help, some days I get sick of hearing myself talking to my wife about this, I tell her "I'm sorry I keep talking about all of this stuff, but when you're in this kind of pain it seems to take over you're life" and then she'll say "it's fine you know I'm always here for you" which she is, but I know she must be pretty tired of it by now. Thats how I think these type of websites help people and family's also. Thanks,,,,Bill
  • SpineAZSpineAZ WiscPosts: 1,084
    An Orthopedic Spine Surgeon would not need the assistance of a Neurosurgeon. A board certified OSS is fully qualified to do surgeries on the spine. I've had 5 spine surgeries in my life and all were done by an OSS. You should get a new OSS or NS to take charge of your care going forward. Personally I prefer OSS.

    The OSS that did my neck was great. But when I came back to him a year later and was in tears due to low back pain he basically brushed me off. But I knew something was really wrong. So through a friend-of-a-friend I found another OSS. He was GREAT. He really listened and his medical assistant is premier. They both supported STD fully after only seeing me once and we worked together on the paperwork. I had L4-L5 spondylolisthesis in 1993 and I just had a hunch that now L3 had moved forward (since L4-S1 was fused). I had tons of tests and the surgeon said he also believed it to be L3 spondylolisthesis though it wasn't clear (it's hard to get good images after stainless steel hardware is in there since 1993).

    BUT, the x-ray I did 2 days prior to the surgery, according to my surgeon, makes it blatantly clear that it's L3 spondylolisthesis. We really think the L3 was mobile so sometimes it was in a near normal position. Whatever the tech did the day of this x-ray shows it so clearly. And in fact she was not a great tech, she had to re-do it a few times and held me in a bent position a bit longer than I was comfortable. It's entirely possible that in her doing that L3 went forward. As we left I was in pain again, so I bet her being incompetent helped me in the end.

    I think the first thing you need is a new doctor who fully understands your level of inability to function (as in the document I sent you via PM). And, if you don't already have it, a Pain Management doctor.

    Having been in the disability insurance business I will tell you that physician cooperation is key. If Sedgwick (well known TPA, by the way) is being told by the doctor that you have no impairment whatsoever then they have no choice but to deny the claim. I feel for you as here you are in pain and you have no one in the medical community supporting your position.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • I think there is some confusion here. If I understand it you have a industrial accident and that is work comp. If so depending on the state you live in and the laws of that state work comp may have the right in choosing the doctor. I would suggest you look at the laws governing your state. You can google "your state work injury" and should lead you to all the laws.

    So now getting down to your STD, Std will not be paying if you were injured at work this is a work comp injury and they are the company who needs to pay. Now here is a kicker if your employer says we have no light duty for you, then work comp is obligated to keep you off work and pay your check at the 66 2/3% till you are able to return to work on a full time basis or are deemed MMI(maximum medical improvement). The one thing you don't want to get in your medical records is that you are unwilling to go back to work, or you are not cooperative. While you maybe boiling on the inside at the doctor try to refrain from saying anything and get out of there and try other avenues. I know you say that your pm doctor really understands you and gets it, keep in mind you are not the client work comp is. One thing I tell all work comp patients is to get copies of your medical records. If you have a attorney they will also see the chart notes and you will see lots of communications going on between the adjuster and work comp as well. Like I say the key is to hold it all in. At the end of the day all these people go home and you have to live with the injury. It is not their families quality of life it is effecting it is yours.

    So now it is Sunday and you will have to go to work tomorrow with the restrictions. But keep in mind your company can reject those restrictions and say no and work comp is on the hook. I had the same situation with my former employer. I was put back to work on light duty, but my employer didn't have light duty it was full or none. They contacted the work comp carrier and told them. When i originally showed up at work with light duty they said go home we will call you. Well that was a nervous two days to say the least. But all in all I was back on work comp's payroll. There are lots of communications that go on behind the scenes, is it legal, yes work comp is the insurance company. I find it a little unethical but till the law changes it is what we have to work with. So I think your best bet at this point and time is to talk to your human resources manager. Some companies deem it as a additional cost to them having a employee working on a light duty and don't want the cost associated with it. Or they can find the risk are to high that they are not going to assume the risk for additional injuries either to the employee or additional employees and in some situations their customer base.

    The other thing I want you to keep in mind under STD no employer has to offer light duty work. STD assumes you were injured on your own and employers are not obligate to let employees return to work under light duty, even after a surgery. Now some employers will and some won't. But those rules are going to be found in your company policy manual. Where you may also find the policy regarding light duty all together. Anyway keep us posted on how you do. Take care.
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