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HR Liaison and WC Insurance Carrier Illinois

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  • HR Liaison and WC Insurance Carrier Illinois

    I fell at work several months ago which required me to have some reconstructive surgery on my knee. My time off (2.5 months) and surgery was covered by WC. There was never any question. While I was off, I needed another minor noninvasive procedure to help get my knee bending again. Once again, never questioned, covered by WC.

    I returned to work. One week later at my follow up appointment, the Dr decided that I needed some arthroscopic surgery to clean up the scar tissue since I was having pain, clicking, grinding, and loss of flexability. My Dr dictated that this surgery was directly related to the fact that I slipped on some spilled chemicals and dislocated my knee while working. I had approval from my employers WC ins carrier. The Dr office had approval (3 weeks before the scheduled surgery) from the WC carrier. I made the mistake of calling the in house WC liaison (two days before my surgery) to ask him to notify my manager that I wouldn't need to use vacation since WC is covering my surgery and time off. That's when all hell broke loose. My employer had never been contacted by their ins. company so I gave him the name of the claims adjuster that approved everything. The response I was given was that she had to right to approve without speaking to my employer first. Therefore, my approval was taken away, my major medical billed (not worried about that) and I had to use vacation to cover my time off.

    I'm in the process getting more documentation from my Dr.to get this approved retroactively so that my vacation will be put back.

    My questions are:

    Can your employer deny a claim before it even goes to the WC carrier?

    Was my employer in the right by telling the ins. company not to approve the surgery until they have had time to discuss my situation with their lawyer?

  • #2
    Your current surgery and time loss should be an extension of your original claim already approved by your employer. It is a shame but employers sometimes try to interfere in WC claims ultimately the IC is the one's who accept or deny coverage. Occasionally it even takes the presence of the board of work comp or industrial relations to get the approval.

    If you are not currently represented by a board certified WC specialist attorney now seems like it would certainly be the time to do so. As you have noted in your post you are aware that your employer is using an attorney to advise them about your WC claim and you need an attorney that is looking after your best interests from a legal stand point.

    Have you had a permanent disability rating for your knee for purposes of payment for permanent impairment due to your work related injury? If you have not and have not otherwise closed your WC claim your employer is completely out of line to interfere with your treatment as it is in essence already approved by the IC from the original injury.

    Hopefully this delay will not cause you further injury. However if it does your employers IC will also be responsible for that additional injury as a compensable consequence to the original injury.

    Good Luck to you.
    Last edited by Kick Me; 09-11-2007, 07:43 PM.
    Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

    Comment


    • #3
      Your story doesn't quite add up and it may be just the way you are explaining it, not that there is a problem. The employer doesn't approve or deny anything other than FMLA. Since you waited until 2 days before the surgery to inform them that you needed to be off for this surgery, they could deny FMLA or at least make you wait 30 days before it kicks in. Yes they can charge vacation even if it is FML or WC. Some employers opt to allow employees to save their accrued time if the lost time is the result of a WC injury, but they are not required to do so.

      Whether it is covered by WC or your health insurance is an entirely different matter and completely between the insurance companies. If itis the result of a work injury, then it would not be covered under 99% of the health plans out there.
      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


      • #4
        It must be the way I explained it.
        I notified my employer on 8/10 that I was scheduled for more surgery on 9/4. I do have a lawyer sho was also immediately notified of my upcoming surgery. He spoke with ths WC ins. company who said they needed my medical records to get this approved. Within a couple of days the ins. co. had my records and had given both my lawyer and Dr. office approval to bill the surgery to WC. So, I think everything is fine, nothing to worry about.
        My supervisor comes up to me a couple days before surgery insisting that I have to use vacation since no one other than myself had said this was approved by WC. I asked her to call the in house liasion for confirmation. The liasion told my supervisor that was the first he heard anything about more surgery. When I spoke to the liasion he reamed me out for having my attorney speak directly with the ins. co. After all these months (accident happened in May) I'm told that's not proper protocol. The liasion made a big stink about it being my 3rd surgery since I fell and he (liasion) kept asking if it was really necessary. Next thing I know, my lawyer gets a call from my employers lawyer (first we've heard from him) saying that despite the fact the ins. co. gave approval and said to bill it to WC it wasn't going to happen that as of right now the claim is denied.

        I guess I'm too wordy, I talk a lot LOL!

        My question was how, if I already had approval from WC, can they go back and review a claim and decide to deny it? I didn't think they could do that. I thought once it was approved by WC it's a done deal?

        Comment


        • #5
          The insurance company can always revoke or challenge a prior approval, but this doesn't just happen because the employer's lawyer tells them to. They don't answer to the employer's lawyer, or even the employer for that matter. It just doesn't make sense that they would suddenly deny it based on something who had no stake in the claim told them. There must be more to the story and perhaps you don't know that missing piece or are mistaken about how exactly this went down.

          Long story short, you have an attorney. That person should be the one advising you on how to proceed and they should be speaking with the adjuster or the carrier's counsel to find out why it is now denied. I'd be scrutinizing a 3rd surgery in 4 months for a slip and fall too. If the medicals support it however, it is what it is. That is why you carry insurance.

          Whether it is appropriate to file issues to get this covered or not, I'll leave to your attorney.
          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


          • #6
            Thanks for the information ElleMD!

            I'd question a 3rd procedure too! The first surgery was reconstructive due to a dislocation. My body has a tendancy to build excessive scar tissue so arthrofibrosis is a problem. I needed a manual manipulation to try to break up the scar tissue. That didn't do the trick so my Dr needed to go in and clean my knee out arthroscopicaly. All my documentation shows that my current condition is attributed to the fact that I had surgery because I dislocated my knee when I fell.

            I was just amazed by my employers response to the whole WC issue. They haven't disputed anything up until now. I just seem to be having a hard time getting myself taken care of which is really disappointing since I work in a hospital where we have one of the top 10 orthropaedic departments in the nation.

            I'm sure you're 100% correct about there being more to this than I understand. I was told by my lawyer and employer that it's my employers atty. who wont even let my most recent claim go to the WC carrier. There really wasn't enough time to take it to the comission so we're still in the process of sorting it out. But now I find out that part of the reason I'm getting such a hard time is my employer was in the process of switching WC carriers.

            Anyway, I really do appreciate your time! Thanks a bunch for the information!

            Comment


            • #7
              Sounds like that missing piece of the puzzle just surfaced. Employer changing WC IC's. What a pity something like that is causing this delay in your treatment. Regardless it certainly IS NOT your employer's attorney's place to interfere in your WC claim. Most states, I suspect Ill is one of them, carry some pretty hefty fines for an employer or their IC when they deliberately deny medical treatment for a WC claim.

              It seems like a no brainer that your claim is viable as you have already had these other procedures completed. Obviously it is not your fault that your body builds scar tissues at an accelerated rate. This sometimes does happen and I expect it is why the IC originally approved the procedure. Speaking of a continuation of care with your WC injury, I have to respectfully disagree with ElleMD as to how you are to be paid for this time off. This is NOT a new claim so there is NO waiting period. You are eligible for TTD benefits from day one when you take off for your surgery. Your employer CAN NOT use your PTO in lieu of the TTD where you have already served the waiting period to be paid TTD from the WC IC.

              It really chaps me to hear of an employer causing a delay in medical care when they are the one who choses the physicians. I could almost concede if you were allowed to go to just any old doc and some just don't have any problem doing unnecessary surgical procedures. It has been my experience that where WC is concerned most all WC docs will go to extreme lengths to avoid a surgical procedure for injured workers. A good example I have been since March of this year trying to get a rotator cuff repair procedure done. I am appalled that it is taking so long. The surgeon, 2nd opinion, has conceded that after the first 2 months in PT with no improvement surgery is necessary. I still do not have a surgical date.

              I hear/read the horror stories of injured workers being referred to as malingers. Through no fault of my own I am now 6 months off work and still will have from 3 to 6 months post operatively before the surgeon will even consider releasing me back to full duty. Had they got it in gear when it was determined that surgery was necessary and went on with the procedure I would now either be back to work or would be in the very near future. This is NOT my idea of fun, in any way form or fashion.

              Hopefully it won't be too long and you can get this necessary procedure done. Good luck to you.
              Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

              Comment


              • #8
                Where did I say there was a new injury or that a waiting period applied? Unless there was a separate occurance that led to this 3rd surgery beingnecessary, and sometimes not even then, this would still be one claim. My point is that the employer may charge vacation whether it is WC or not. Most often the way employers do this is they use vacation leave to make up the 1/3 that TTD does not pay. It is perfectly legal to do so.

                The waiting period I mentioned was only with regard to FMLA in the event that 30 days notice was possible but not provided. That has nothing to do with it being WC.

                In IL, employees do choose their own medical providers.

                If the employer is changing insurers, heaven help you... and them. Changing a WC carrier is way more difficult and complex than changing say a health insurance provider. Talk to your lawyer. See if filing for an emergency hearing is appropriate.
                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


                • #9
                  Quoted per ElleMD: "Yes they can charge vacation even if it is FML or WC. Some employers opt to allow employees to save their accrued time if the lost time is the result of a WC injury, but they are not required to do so."

                  Here is a very good start of where you implied that the "employer can charge vacation if it is FML or WC." An EMPLOYEE has the option of using PTO to make up that 1/3 is in not necessarily automatic that the employer would do so. In fact it is outside the norm as MOST employers conger up some half baked reason to terminate the injured worker who has filed a WC claim. Why would the employer ever consider paying the 1/3 difference in PTO when they know once the employee is termed they will forfeit that PTO in most states? So in reality I guess you didn't SAY they could substitute PTO for WC you certainly inferred that they could. That response was directly in relation to Jessica's first post where she says, they charged her regular insurance and her time off to PTO. That bell is just a little hard to unring don't you think?

                  Further, she was a mere 6 days short of a 30 day advance notice for taking FML. I suppose IF the employer really wanted to split hairs then they could deny her the use of FML for those additional 6 days. Then on the other hand IF the doctor feels like time is of the essence he simply needs to state such and the FML is considered needed on an emergency basis and the 30 day notification is then null.

                  Regardless of how this situation developed I expect that if her attorney is a certified WC specialist that the end result will be WC, regardless of a change of carriers, will be on the hook for the surgery and her time off work.

                  Jess be sure and post back and let us know how things turn out. Good luck to you.
                  Last edited by Kick Me; 09-14-2007, 02:53 AM.
                  Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

                  Comment


                  • #10
                    You are operating on a lot of assumptions here and generalizations that just don't bear out in reality. I think your personal experience is coloring how you look at other cases. What you experienced simply doesn't apply across the board. It is illegal to fire an employee just because they file a WC claim and the vast majority of employers aren't going to break the law nor wish to incur the expense of recruiting, and training a replacement. Not to mention the morale problems that would result from treating employees so calously. It is to an employer's benefit to get the employee back and working again rather than terminating and paying TTD.

                    The WC carrier doesn't decide FMLA and the employer doens't decide what gets covered. We clearly don't have the full story here and perhaps the OP does not either.
                    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


                    • #11
                      Nice try there ElleMD but for your information my situation is quite the opposite of the OP's. I still have my job and will have when I am healed and ready to RTW. So my personal experience has been quite amicable. I work for a decent employer who knows how to treat their employees with decency and respect.

                      The OP has provided ample information to clearly see that the employer is in direct violation of ADA/FHEA laws and she needs to do as suggested and invoke her right to have the employer enter into the "interactive process". This needs to happen with a good faith effort to restore her to employment with or without reasonable accommodations due to her present disability. She even states that the one restriction, lifting, her doctor has placed her on is not applicable to her position as an office workers. It isn't hard at all to make a determination from what she posted to easily see the employer is NOT following the law in her situation.

                      As far as the WC determining FML, don't have any idea where that comes from. I certainly didn't suggest any such nonsense. I am very well versed int he working of FMLA and I agree fully WC has nothing to do with FMLA other than a work injury may be the basis for the need to take FMLA when otherwise qualified. Again I can only restate there is plenty of information here to see what is happening. Jessica clearly stated form the OP and then added to it. Not too much more need be added to make a rational conclusion of what is up. Perhaps looking from the other side of the fence but from where I stand it isn't hard to see at all.

                      Beyond that this petty debate you want to continue is over as far as I am concerned. My remarks were for the OP and she can either follow up on it or not. Her choice. She has the resources and information she needs to proceed if that is what she chooses to do. She also has the services of an attorney so hopefully he will be good at what he does and she will get the needed procedure sooner rather than later. She was not initially given this information by previous poster so I gave it to her to use as she sees fit.

                      Have a good day.
                      Last edited by Kick Me; 09-14-2007, 03:00 AM.
                      Information posted by me is my "OPINION". I do NOT give legal advice to anyone as like most here I am NOT an attorney.

                      Comment


                      • #12
                        Since the poster has an attorney, I suggest that she direct any questions regarding ANY of their rights to them. I do not agree that this is as cut and dried as you appear to think. But the attorney is the proper person to be determining whether the ADA has been triggered, no a stranger on a message board.
                        The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

                        Comment


                        • #13
                          Originally posted by cbg View Post
                          Since the poster has an attorney, I suggest that she direct any questions regarding ANY of their rights to them. I do not agree that this is as cut and dried as you appear to think. But the attorney is the proper person to be determining whether the ADA has been triggered, no a stranger on a message board.
                          Sorry everyone! I didn't mean to stir the pot!!! I appreciate the responses! I've never had to deal with lawyers or WC before so I'm pretty much ignorant about what I should be asking. My lawyer has spent a lot of time explaining the WC process to me. I pretty much understand what my employer can and can not do. Every once in a while sometihing comes up that I question and since I've gotten a lot of valuable information from this board, I thought I'd ask here. This board is a great resource! Sorry for causing a problem, I'll take cbg's advice and stick with my attorney.

                          Thanks again!
                          Last edited by Jessica87; 09-14-2007, 08:26 PM.

                          Comment


                          • #14
                            Jessica, you have not caused a problem. Please don't think that. There can often be honest, legitimate disagreements even among experts as to when and how certain laws apply, and this is one of them. Both Elle and Kick Me have made legitimate points. But the bottom line is, a message board can only give general information, not specific legal advice.

                            I hope you'll give us the benefit of the doubt and come back if we can help you sort through the often very confusing laws.
                            The above answer, whatever it is, assumes that no legally binding and enforceable contract or CBA says otherwise. If it does, then the terms of the contract or CBA apply.

                            Comment

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