Workers Comp denial

Workers Comp denial

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Verminator
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Workers Comp denial

Was denied the surgery request by the Work Comp Ins co. Doctor did write in his report my neck issues were not caused by work, but just arthritis causing bone spurs and it was just a waiting time bomb for something start happening. I think an injury I had last year in October, banged my chin had falling off a ladder, may have caused the "time bomb" to go off.

So, do you all think I may have a case for appealing?
I do have private insurance through work, but would rather not have to put out the co-pays.

yasmina
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Verminator wrote:Was denied

Verminator wrote:
Was denied the surgery request by the Work Comp Ins co. Doctor did write in his report my neck issues were not caused by work, but just arthritis causing bone spurs and it was just a waiting time bomb for something start happening. I think an injury I had last year in October, banged my chin had falling off a ladder, may have caused the "time bomb" to go off.

So, do you all think I may have a case for appealing?
I do have private insurance through work, but would rather not have to put out the co-pays.

I think I would appeal. Did you document the fall off the ladder with your employer?

I had a similar situation. I apparently had the same thing - arthritis causing bone spurs. While cleaning house about 6 weeks before my surgery I fell on my right side. Within days, my right arm grew progressively numb and tingly, along with pain. So apparently, that was the cause of the exploding time bomb.

Unfortunately, if your fall isn't documented, you may not have much of a case though - difficult to prove.

Best of luck

Karen (AKA yasmina)

retiredbosn
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I think that I would have a

I think that I would have a talk with the doctor. If putting off the surgery puts you in more of a risk for permanent nerve damage then put out the money. Studies show the longer we leave nerves sending pain signals the more likely we are to suffer with chronic pain. I think that this one thing is a lot of my problem, I waited 18 months before I let the doc operate the first time, and now I pay the price, everyday. Good luck.

Verminator
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fall was documented

Yes, I did go to the ER for my fall. I had 10 stitches inside my lower lip and 10 outside. I never complained of a sore neck at the time. Then I noticed the numbness and soreness in my left arm about 4 months later. Same insurance company too, so they had all the records.
I think I will pursue it further with my own insurance. Like retiredbosn says, I dont want any further nerve damage.

saltzworks
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I wonder if the first

I wonder if the first position for WC is ALWAYS deny.

If you had no problems until after the fall, then the fall triggered something. You might have had a few more years before having to seek surgery if you had not fallen. Would you have had problems in the future - possibly, even probably, but the fall sped up the timetable.

I would talk with dr., maybe even go ahead with surgery if it's necessary and putting out your co-pays. But I might still bring in a lawyer for an appeal.

DNice
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Sorry to hear

Sorry to hear about your issue.
My guess is you are being denied b/c it took 4 months before your pain. I assume there are some limits to the injury to pain appearance symptoms. I'm not a lawyer or in insurance but just reading this, I suspect that is why.

But that being said, always worth pursuing an appeal.

Meantime, don't delay taking care of yourself. You have an injury and insurance. Co-pays stink but not as bad as permanent nerve damage pain.

SpineAZ
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WC

The advantage to using your own insurance, vs WC, is that WC tends to dictate what treatment you'll have, where you'll have it, who will do it, etc. With your own insurance you have more control (especially if you have a PPO).

Multiple ACDFs, Multiple Lumbar Fusions; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty

backman01
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workmans comp

Bone spurs is wear and tear on the joints that is normal,when you fell you should have had it documented,or workmans will not pay that is the way comp is weather you felt pain or not again should have been reported.you could ask a lawyer but i dont think you have a chance. you will have to use other insurance and pay 20% thats normal.
Rick ncpa

Verminator
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I did report the fall accident

I did report it to Workers Comp. In fact it is the same insurance company handling my neck issues.
I am planning on starting the process of my own insurance company to take care of my surgery, but will contact an attorney I was referred to by a work associate.

saltzworks
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It sucks to pay out

It sucks to pay out deductibles when you don't feel that it is your responsibility. I know, I've been paying thousands so far. It really sucks. It's SO much money (not to mention pain and crap) to have to go through just from one stupid accident.

tamtam
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Prevailing factor

Not sure what state you live in. But most states work on the prevailing factor of the injury. Your surgeon would need to write that your injury was caused by the fall you had from the ladder or it was the prevailing factor in your need for surgery. So you can have DDD, as most people do after the age of 25. However most don't have symptoms from it either. So if your fall was the prevailing factor in your need for surgery and the surgeon states that, you may have something. Keep in mind that they will also request the previous 5 years of medical records through any insurance carrier you had during those times. So if you had treatment for anything related more than likely you will not be able to deem it work comp.

Now the good news as stated above using your personal insurance is normally a much better fit. You don't have to worry about the treatment being dictated to you. Although I understand the co-pays are high you will never have to report that injury to a potential employer nor will you have to qualify it with your current employer. Your doctor will not be under the watchful eye of work comp and be pressured to send you back to work either. You will have no disability rating that you will have to report to employers. Your surgeon will be working directly for you and you can maintain the doctor patient relationship. Keep in mind under work comp there is no HIPPA at all. In my opinion work comp is only workable when it is a minor injury, the more serious injuries you would rather be in your private insurance .

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