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  • Complex W.C. problem in Hawaii

    I had been seeking treatment for a low back injury which had not been disputed by the Employer/Carrier. My MD made a referral for me to return for a follow up with a spine surgeon, since all conservative treatments had failed. After these referrals were denied by W.C., my attorney advised me (in writing) to get the treatments approved by my HMSA health insurance (Gov.) he said that as long as he could show that the Employer had wrongfully denied these treatments that the W.C. carrier would have to reimburse HMSA, and that I would not have to pay for them either way. I had been unable to work for months and had been recieving TTD but I had developed a sever case of sciatic pain which was immune to my pain killers (morphine). I went to see my MD and asked him to refer me back to the surgeon. My MD said that I did not need him to make a referral since I was pre approved by HMSA. I explained to my MD that he still had to submit a request to the W.C. carrier, and then show HMSA the denial. I returned to see the surgeon and he said that he could do a Microdiscectomy to relieve the severe and progressively worsening sciatica pain, but made it clear that this proceedure would not help my back pain, and that I would probably need a fusion or artificial disc replacement for the back pain, which had been the primary reason for my disability. I had the surgery on December 9 and returned home without the sciatic pain only to find a letter by my attorney dated December 9, the date of surgery. In this letter he stated that he had recieved a letter from the W.C. attorney stating that they were denying the surgery because the MD had not complied with W.C. rules and had not even submitted a request for the surgery. The letters dated Dec 2 stated that " I advise you to carefully review the medical evedince and advise your client accordingly" and also warned " if your client proceeds to have the surgery he will be jeopardizing all his future W.C. benefits" I was shocked to see this, and could not believe that I had not been warned beforehand, I have a wife and a young baby to provide for, so I would never had jeopardized my benefits which we rely on to survive. The W.C. carrier terminated all my W.C. benefits on December 9 as they had warned. My attorney said that he would address this at a hearing and not to worry that he could straighten everything out. We went to hearing January 27 and the Director gave us an extension to get a report from the surgeon on my behalf. The report arrived April 1, and the director rendered a decision on April 15 that stated "the claimant and his providers disregarded WC regulations by having the proceedure through HMSA" and stated that "justification of the proceedure fails to be the issue when there has been non compliance with W.C. regulations" and finally " the Employer is not liable for the surgery of Dec 9 nor any resulting disiblity, and the Employer's liability in this matter resumes once claiment is determined to have attained pre-surgery status" I then made an appointment with the surgeon who performed the proceedure on May 4, and asked him to determine when I had reached pre surgery status. He wrote a statement that I had attained pre-surgery status on Jan 22 aproximately six weeks after the surgery. The Employer refuses to resume my benefits and says that they don't put much validity in his statement. The surgeon has since wrote a note clearly describing why I had attained pre-surgery status and stated that my current disability has nothing to do with the surgery of Dec 9, but that it is caused by the remaining low back injury which he did not address, and that as he had previously stated I would need further treatment for. It is now almost seven months since the surgery, and the Employer refuses to resume my benefits as the decision said they were supposed to. They have scheduled an IME evaluation with their MD for Aug 4, and will not pay me in the mean time, or pay for any treatment. I cannot believe that my previous attorney, who has since been fired, could have allowed this to happen. I cannot believe that the Employer Carrier can refuse to resume my benefits, even though they have been provided all neccessary notes by the MD's. I have requested a hearing on the matter at the Dept. of Labor to force them to resume my benefits, but it usually takes 8 weeks to get a hearing and then another 4 to 8 weeks for a decision. I have already gone almost seven months without my TTD and do not have any savings left, and they know this and are trying to get me to settle and sign away my future medical rights even though I am still disabled and still need treatment. Is there any recourse?

  • #2
    Assistance

    I will be very happy to assist you please contact me via private e-mail at [email protected] or you can call me at 217/390-4299 Linda ie LMay
    This is my area of expertise I am an OSHA Institute Instructer , Safety Engineer , an RNBSN and NREMT with National registry status I have over 30 years experience in this area and will be more then happy to assist thanks LM
    I have done many case similar to yours you may call me at what ever time is the easiest for you thanks LInda

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