tried not to use workers comp

[aadler]

What is the name of your state? Texas
Called in a shoulder injury and then used my personal insurance to see my personal physician and orthopedic in an effort to not have to file a compensation claim from workers comp, getting anti-inflammatory medication. I always characterized it as what it was and how it happened. Now I find that the injury requires surgery and I am seeking compensation from workers comp. It was disputed the first time as being a non-surgical injury and that I used my own insurance. An MRI disproved the first item. Is the insurance issue a problem? I searched the TWCC website for any information regarding that but nothing was found, a call to them verified nothing is stated. On a google search I found that you should notify of an injury and when you are ready, file a claim for compensation, which is what I did. Thanks for any insight. My case is in review.

 

[Beth3]

By not notifying your employer timely that you had a work injury and by using your personal insurance for your initial doctors visits, you really complicated your situation. (By the way, you would necessarily have had to indicate this was not an occupational injury when you had these doctors visits or else your personal health insurance never would have covered it.)

Looking at this from the your employer's and their WC carrier's perspective (who necessarily have to view these situations with a somewhat jaundiced eye), it wasn't a WC claim until you were told you needed surgery and now it is??? All you can do in the interim is wait for the WC carrier to make a determination on their liability for your injury. If they deny the claim and you wish to dispute it, you may file for a hearing with your State's Worker's Compensation Division.

 

[aadler]

Actually I did inform them of my injury 2 days after it occurred. I then sought to resolve it with medication and not have to file for compensation. If it had been just a sprain or strain, that would have been the end of the story. When I checked out at the orthopedic the first time, the girl asked if it was a work related injury and I said yes. No one said you can't use your own insurance for a work related injury. All my doctor's narratives indicate work related injury. Since I wasn't looking to be compensated unless it was something extensive, it appears I shot myself in the foot. For someone like me who has never had to use this, where would I find something like that out, especially if I didn't think it was out of line? I guess not wanting to claim compensation from workers comp isn't the norm.

 

[tjr5150]

If you told your employer,did they have you fill out a incident report? Also if it was work related why would you use your personal insurance? Sounds to me like your not telling the whole story.

 

[aadler]

I called in an incident report to their carrier which is what the policy is, they take down all the pertinent information. I have a witness to the injury as well, but I am of the school that you don't use insurance for a broken window pane, you wait till lightning strikes and burns your house down.

 

[tjr5150]

I understand what your saying. by using your own insurance worker's comp will dispute it, and ask why didn't you make a claim.i understand your point of view. will your insurance pay for a surgery? if it will good, the only problem will be when your in the recovery phase you will not get paid from time away from work unless you have a seprate insurance carrier for that, like aflac or something

 

[aadler]

what a mess I made.

 

[Lisabyday]

You may have made a mess but it is not one that can't be corrected; albeit; it may be tricky.

You must provide notice within 30 days of the date of the injury. The notice may be verbal or written; however, it has to be made to the employer or supervisor. According to your post you notified the insurance carrier (which was your company's policy). At that time you should have been provided a TWCC-41, which must be filed with the Workers' Compensation Commission within one year of the injury or realization that the injury or illness was work-related. After you gave notice, your employer should have reported the injury to the Texas Workers' Compensation Commission within eight days of receiving notice of the injury.

Immediately upon receiving notice of the injury, the employer should have provided you with information about the services provided by the Texas Workers' Compensation Commission.

Question- are you saying that the company’s policy requires you to notify the insurance carrier rather than the employer or were you required to do both? And, if so, did you notify the employer as well as the insurance carrier? If you notified both the employer and the insurance carrier (timely notification is 30 days according to Texas law) the employer should have taken the next step. If you notified the employer and insurance carrier and neither provided you with any sources of medical treatment - then you using your own insurance takes on a whole new meaning. Need clarification. Alesia

 

[Lisabyday]

You may have made a mess but it is not one that can't be corrected; albeit; it may be tricky.

You must provide notice within 30 days of the date of the injury. The notice may be verbal or written; however, it has to be made to the employer or supervisor. According to your post you notified the insurance carrier (which was your company's policy). At that time you should have been provided a TWCC-41, which must be filed with the Workers' Compensation Commission within one year of the injury or realization that the injury or illness was work-related. After you gave notice, your employer should have reported the injury to the Texas Workers' Compensation Commission within eight days of receiving notice of the injury.

Immediately upon receiving notice of the injury, the employer should have provided you with information about the services provided by the Texas Workers' Compensation Commission.

Question- are you saying that the company’s policy requires you to notify the insurance carrier rather than the employer or were you required to do both? And, if so, did you notify the employer as well as the insurance carrier? If you notified both the employer and the insurance carrier (timely notification is 30 days according to Texas law) the employer should have taken the next step. If you notified the employer and insurance carrier and neither provided you with any sources of medical treatment - then using your own insurance takes on a whole new meaning. Need clarification. Alesia

 

[aadler]

I did receive a TWCC41E but I believe it came from TWCC, not my employer. My employer sent me 1 page that said "helpful info while out on occupational injury". It gave phone numbers of adjusters, breakdown of how I would be paid, what to send them if off of work, and the website address for twcc . Nothing was received on how to go through this other than to see a doctor that was approved as Texas certified. My supervisor did send me a form for family leave request but that was the only other thing I received from them. I heard from no one at insurer until after I found surgery was needed and I contacted them again and informed them. I have not missed any work at this point. I also had not talked to my adjuster ever although I called 11 times from my cellphone (not counting any made from my home phone) over the next 6 weeks, leaving messages once a week, asking if there was anything I should be doing. She never answered, not once. she did leave a message one time to call her back but I never was I able to get hold of her. She sent a dispute showing claim denial due to "it being a sprain or strain and that I knowingly used my own insurance". She sent it to the wrong address although everything else came to the right address. The doctor thought everything was a go because the insurer's medical advisor approved the procedure which I also got. When their prescription provider declined my postmeds I realized maybe something was wrong although they said they just needed an updated file. She never contacted them either. The morning of surgery, I called every adjuster till one answered and let me hold to talk to her and I found out about the dispute, a copy which she faxed to me that day and I saw the wrong address. She suggested I go ahead with the surgery which I declined in case they needed more evidence/xrays. For someone who doesn't even have a speeding ticket in over 40 years and not one disciplinary action at work in 20 years nor have I ever asked for and been denied or asked for and received any worker's comp, this is a nightmare. Sorry if it is fractured and thank you for any insight. Right now they have requested all my medical records from my primary care dr., I assume to check for past history on the condition which is nil. She suggested that I put in for a benefit review conference but I don't know what the dispute would be for yet. I guess that does mean it will be denied. Should I contact my personal insurance and reimburse them now for what they have paid, which is my inclination? Thanks again.

 

[aadler]

Question- are you saying that the company’s policy requires you to notify the insurance carrier rather than the employer or were you required to do both?

They have a phone number posted to call to report a new injury (to the insurer) and I assume that the insurer then contacts my employer because the employer sent me the page I referred to in the previous message. My supervisor sent me the family leave form when I informed him that surgery would be necessary, but that was months from the time I incurred the injury.

And, if so, did you notify the employer as well as the insurance carrier?

No.

If you notified both the employer and the insurance carrier (timely notification is 30 days according to Texas law) the employer should have taken the next step. If you notified the employer and insurance carrier and neither provided you with any sources of medical treatment - then using your own insurance takes on a whole new meaning. Need clarification.

I did notify the insurer 2 days after the injury and received the one page from my employer within a week or 2.

 

[Lisabyday]

Perhaps, the defense to the claim is that you did not give proper notice. Nonetheless, according to the law - notice has to be given to them within 30 days either by you or someone on your behalf. This has been satisified due to the fact that the insurance carrier notified the employer on your behalf within the 30-day time frame. The employer or the insurance carrier should have provided you with an authorized treating doctor which it does not appear they did.

The denial letter is vague. If no medical treatment was offerred at the time you reported this injury then it would be common sense that you seek medical treatment. However, common sense and the law often do not go hand in hand.

If you need the surgery, by all means have it. Although it is admirable that you want to reimburse your personal insurance carrier for this injury; I would think that doing so would be a bit premature at this stage. Let your personal insurance carrier pay the claim and if warranted they can subrogate - which means they can go after work comp in order to recover their expenses if it is determined at a later date that this is a work comp injury.

As to their requesting all your medical records - I am not certain how it works in Texas (got to check on this one); however, in most cases signing a blanket release to medical records may not be neccessary. I would start off by authorizing the release of specific medical records. For instance, a blanket release may ask for any pyschological exams which, at this stage not neccessary.

Based on what you have said, proper protocal was not adhered to. Somebody should have given you the correct steps to take. Contact a workers' compensation attorney to file a case for you. Most work on a contingency basis and their fees are usually a certain percentage of recovery. I know this has been dificult but I don't think that letting the workers' compensation insurance carrier off the hook so easily is the route to take. Hope this helps. Alesia

 

[aadler]

Thank you for something to grasp onto. I did sign the medical release after checking with the Texas Worker's Comp Commission and the IAM union official familiar with these types of cases and finding that they are within their rights. Need to check to see if the adjuster has indeed taken the next step of requesting them.

 

[Lisabyday]

In addition to any telephone call you make to anyone - follow up with a letter. Seems like you are going to have to document everything that you do. Somehow telephone conversations and their contents are often forgotten. Alesia