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Injured at Work - Claim Denied - Please Help! California California

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  • Injured at Work - Claim Denied - Please Help! California California

    I was injured while working as a home health aide. My employers are relatives. However, I am paid by the state.

    Is it usual and customary to automatically deny my claim because I work for a relative?

    Do I have a right to receive benefits while this three-month long decision is made?

    Do I have to go to the insurance companies doctor?

    Not only did I choose my own doctor when I filled out my forms over a year ago, but also was seen by my doctors office after injury. Only problem is that when I scheduled an emergency appointment I was told that the doctor that could see me the soonest was able to handle wc patients when in fact that was not true. He gave me medicine and, long story short, I have to wait until Tuesday to see the correct doctor so that he can properly indentify/diagnose my injuries.

    Any help will be greatly appreciated.

    Thanks in advance.

  • #2
    Das ist in der Doktor!

    Originally posted by Mildred View Post
    I was injured while working as a home health aide. My employers are relatives. However, I am paid by the state.

    Is it usual and customary to automatically deny my claim because I work for a relative?

    Do I have a right to receive benefits while this three-month long decision is made?

    Do I have to go to the insurance companies doctor?

    Not only did I choose my own doctor when I filled out my forms over a year ago, but also was seen by my doctors office after injury. Only problem is that when I scheduled an emergency appointment I was told that the doctor that could see me the soonest was able to handle wc patients when in fact that was not true. He gave me medicine and, long story short, I have to wait until Tuesday to see the correct doctor so that he can properly indentify/diagnose my injuries.

    Any help will be greatly appreciated.

    Thanks in advance.
    Here's something to look at while you wait until Tueday, hope this helps.
    http://workerscompensation.com/california.php

    ..__________________
    ~ VOTE ALL INCUMBENTS OUT IN 2012,
    WE NEED TO MAKE ROOM FOR A NEW BATCH OF CROOKS !!

    Comment


    • #3
      I was injured while working as a home health aide. My employers are relatives. However, I am paid by the state.

      Is it usual and customary to automatically deny my claim because I work for a relative?
      You don't "work for" your relatives...you work for the State of Calif, presume SCIF/State Compensation Insurance Fund is handling this claim.
      Not only did I choose my own doctor when I filled out my forms over a year ago, but also was seen by my doctors office after injury.
      If you predesignated, and your Dr agreed to treat a work injury, you may continue to treat with that Dr as PTP/Primary Treating Physician.
      Only problem is that when I scheduled an emergency appointment I was told that the doctor that could see me the soonest was able to handle wc patients when in fact that was not true.
      Who told you that? If the Dr you saw is in the same practice...or a PA or Nurse Practioner in the practice, those may treat your injury.
      (2) A “secondary physician” is any physician other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee.

      http://www.dir.ca.gov/t8/9785.html

      (c) The primary treating physician, or a physician designated by the primary treating physician, shall make reports to the claims administrator as required in this section.
      http://www.dir.ca.gov/dwc/dwc_newsli...ine_00-01.html
      I have to wait until Tuesday to see the correct doctor so that he can properly indentify/diagnose my injuries.
      That would be true...you did predesignate your PTP, that would require an initial evaluation and PTP First Report of Injury to certify benefits due. Including medical care, and/or wage replacement benefits.
      You could see any other Dr/PA/NPA in the practice AFTER the first evaluation by YOUR PTP...you must have only one PTP at a time.

      More info in the Fact Sheets for Injured Workers here http://www.dir.ca.gov/dwc/InjuredWorker.htm
      If you need additional help, contact a Information & Assistance officer...800# in your phone book, or go to www. caaa.org for names of Applicant Attorneys in your zip code.

      Comment


      • #4
        How do you know the claim was denied? It sounds like this just happened? What is with the 3 months? If you haven't seen a doctor how do you know you will be out of work for 3 months or that it will take 3 months to determine if you have a viable claim?

        Whether a claim is accepted has nothing to do with who you care for and much more to do with the nature of the injury and the work related duties you were performing (or not) when injured.

        If your claim is denied, you can appeal.
        I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

        Comment


        • #5
          Thank you drruthless, CAIW and ElleMD for all of your help. Below are answers to the questions:

          Who told you that?
          The receptionist that scheduled my emergency appointment told me that. I believe the person she scheduled is a physician’s assistant or physician in training. I believe he is doing something like an internship or externship before he can practice as a physician on his own.

          He prescribed pain meds and walked me to the receptionist to see if my doctor could see me on that day (to do a doctors 1st report). The receptionist had already left for lunch.

          Because it is difficult to reach their office on the phone we both thought it best that I wait for her return. Upon her return, she stated that I could not see two doctors in the same day and rescheduled me to return on tomorrow, Tuesday.

          How do you know the claim was denied?
          You are correct. I spoke in error. I received a letter titled ‘Notice of Delay in Determining Liability’. It said that SCIF had until July 21, 2012 to deny or accept my claim. That’s where the three months come in.

          I actually feel a little better now. I don’t think I will be out of work for three months myself. I was in so much pain initially that it felt like I would be out for months.

          Assisting folks that lose their balance unexpectedly of course, caused my whole body to hurt (from the neck down). This happened repeatedly as there was no other person to step in and help out for a few days. I worked two days and had to lift 'dead' weight at least five times.

          It sounds like this just happened?
          It did happen just last month (April).

          Comment


          • #6
            You have to be out of work for 3 days before TTD/Temp Total Disability kicks in. After 14 days... those first 3 would be picked up.

            You are entitled to medical care, subject to UR process...up to 10 thousand dollars during the first 90 days, that is the time SCIF has to determine compensability.
            Once you have PTP/Primary Treating Physicians first report, if SCIF denies the claim...you must be given the opportunity to request a panel of QME's from the medical unit.

            That process can take several months, and no benefits would be due during that time.
            I received a letter titled ‘Notice of Delay in Determining Liability’. It said that SCIF had until July 21, 2012 to deny or accept my claim
            That's is commonly referred to as a "NOPE" letter, Notice Of Potential Eligibility of benefits... any time your status changes, you are to be sent a NOPE letter.

            It would help you a lot if you would read the Fact Sheets for Injured Workers here http://www.dir.ca.gov/dwc/InjuredWorker.htm
            she stated that I could not see two doctors in the same day and rescheduled me to return on tomorrow, Tuesday.
            That's plain BS... you were evaluated by a PA/Physician Asst... that PA works under your PTP license... the receptionist was making that up, and probably due to time constraints. Unbelievable...

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