Tuesday, July 15, 2014

It's Just Work Comp

A former work comp adjuster and now a legal assistant for a work comp/personal injury in Oklahoma, wrote to me the other day about a claim that has been pestering her for too long.

Pestering as in she has been helping her attorney on a claim that has lingered far too long, resulting in unnecessary disability, and likely will result in the complete lack of employment in the future for this injured worker.

She sent me a copy of the letter she sent to the injured worker's treating physician outlining the history of the injury and treatment, or more accurately, lack of treatment in a timely manner and I need not repeat it here - the history is convoluted and lengthy as one would imagine from a 2011 injury claim that is still "active" in 2014.
Bowzer: "What's the Big Deal?"

In the meantime the injured worker racks up 61 weeks of temporary total disability awaiting the proper treatment.

The most important piece of the story, however, is this former adjuster's recognition of how this happens, that she was a part of this, and that this case is unfortunately exemplary of the state of workers' compensation around the country.

She wrote to me:
Awareness is important in these matters.  Everyone has to understand the impact our decisions have on the innocent bystanders, which in most cases is the injured worker.  After all, what does the general person know about the practice of medicine, diagnosis, and surgical procedures.  They are trusting the folks in the white coats.  We grabble and argue with one another and these people are caught in the middle and have no control over anything.  Caught in perpetual turmoil.  How many of us would put up with this?  Do you want some adjuster, who lives and works in another state that you have never even met making decisions that impact your life?   

It is wrong on so many angles, including my own.  I am certainly not without sin in this matter. However, I am glad that ultimately I did the right thing and have not pushed for litigation to authorize an unnecessary surgery that would more than likely leave my client worse off than he is now.    

This crap is nationwide.  I mean, really why is there so much controversy in work comp?  It doesn't seem to be present so much in other areas of insurance such as personal health and third party liability. You know? Let's say you have personal health insurance, you go to your doctor because you injured your back.  You may get a letter from your carrier asking how you injured your back.  You answer stating I injured my back at home digging a ditch.  Your health insurance pays for your treatment. There is no court proceedings.  There is no fall out from your employer because you have to take time off work to attend physical therapy or whatever.  You are not suddenly held under a microscope and made to feel like a liar.  No, you just get treatment that is paid for per the provisions of your policy.  

So why isn't the same with the work comp injury?  You injure your back at work.  You should receive treatment as outlined in the provisions of the work comp policy.  Of course the work comp policy is defined generally by the state.  In Oklahoma that would be Title 85 or Title 85 (A) depending on the date of injury.  As a work comp adjuster I need to apply benefits as provided in the provisions of the work comp title.  It isn't rocket science.

Indeed, why is there so much controversy in workers' compensation? 

It isn't rocket science - but we keep trying to make it so, with "evidence based guidelines" that are more about politics than science

And even if such guidelines were scientific, why does there have to be review after review, resulting in delay after delay?

What's the big deal?

Maybe a clue is in the deals that go on within work comp such as private equity firms buying claims adjusting firms for a billion or so dollars.

Or maybe its within short-sighted authorship of laws meant to transform dysfunction but resulting in greater confusion and ambiguity.

Maybe we try to make work comp too much about who's right or who's wrong rather than just recognizing that this is a privatized (for the most part) social benefit system.

Maybe we shouldn't emphasize "costs" when we all get together at our think tank type conferences - group think that puts all of the focus in the wrong places.

Maybe we need to reconfigure the conversation and instead of asking why things cost so much we should instead be asking why there's any controversy at all.

Remember? Work comp is a No Fault system. It's not my fault. It's not your fault. It's not the fault of the employer, the worker, the attorney, physician, broker, carrier or whomever ... unless timely and appropriate benefits aren't provided.

THEN we have fault, controversy, hearings, appeals and ... costs.

It's not rocket science. It's just work comp.


  1. How about Mental Health Pain?: Folks I need help, I don't like asking, but I do. These folks in my state don't want comp fixed. Patients and workers are being harmed, I want that stopped, but no one in office nor any one running for office will admit that our comp is broken and harming folks. So PLEASE PLEASE call this man or write to let them know the TRUTH Peace PLEASE CALL OR email and let this man know that workers comp is broken. His office asked me what I think they should do. I told them what I think they should do. HE he he he.

    This is my States labor leader and Workers Comp Chairman, but he don't know what to do about a broken workers comp? Hmm?

    THAT HAS PATIENT ABUSE happening in it making our iw's mental health even worse out of the injustice.

    PLEASE CALL and let this man KNOW THE TRUTH that I think he all ready knows.

    There For the People?

    I just called, and left a message this tiem and also asked him when his term is up? and what it will take for me to run against him. IM sick and down but I will not tolerate men stealing our grand bargain and allowing patients to be harmed and abused and then have him say he STANDS FOR LABOR when he turns a blind arrogant eye the abuse and theft our GRAND BARGAIN.

    Unitl you have LABORED a life time MR> SELLS my Teacher and polotician friend. You will never value our grand bargain.

    And so should not be standing up for labor as if your some HERO, for your your harming us just as much as JAY with his big biz friends over the Laborers interest also. Funny you bashed Sen. Larsen yet you now you do the same thing to labor you accused him of and would not endorse him with YOUR Labor council. Yet you both turn your backs on patient abuse and consumer ins. fraud on the Labor you all say your there for.

    So even if Im sick in head over all this, I still can not stand back and allow this abuse of labor and patients to go on with doing something.

    Im going to ask for a RECALL, unless his term is up soon. I have to look into that.

    BUT PLEASE LET THIS MAN HEAR the INJURED Workers Voice For it is HE NOW that is blocking change of a broken system from happening for labor and patients in WA State.

    Rep. Mike Sells

    Olympia Office:
    132B Legislative Building
    PO Box 40600
    Olympia, WA 98504-0600
    (360) 786-7840

    E-mail District Office:
    2812 Lombard Ave.
    Suite 210
    Everett, WA 98201
    (425) 257-2168

  2. Nice post. Inspiring. Bottom line. Follow the Money.

    In California, and elsewhere, the problem really seems to boil down to attorney-doctor-adjust fraud, in collusion with various State Work Comp agencies. FOLLOW THE MONEY.

    Take my case. I wasn't 'properly noticed' on any alleged MPN. The manager said, "you can see any doctor that takes work comp insurance' and gave me an incomplete DWC-1 form...no insurance info on it. No doctor would take it. I had to use CIGNA employee insurance the first several weeks.

    Then I retained an attorney who insisted it was illegal for me to use employee insurance and that HE was responsible for finding the right doctors for me, so just wait, and he didn't need my help. SO I WAITED.

    While represented, the adjuster promised that if I was not represented, he would help me get medical care. Another lie. Date of injury, January 9, 2012. All I knew is that the lawyers could not/would get me any help, and my brain was all messed up.

    The first law firm sent me to an ORTHOPEDIC SURGEON and chanted 'there is no psych component to a work injury'. I said, "Lady, it's not a psych component, IT'S MY BRAIN, LOCATED INSIDE MY HEAD THAT GOT CONKED ON 1/9/12"

    By mid-year, defense legal counsel got involved, starting the pattern and practice of omission of records and ignoring all requests for medically necessary treatments. (The F-word, Fraud, bothers them, but the actions are exactly as stated in the CA 2012 fraud warnings.... so, if it looks like fraud, gets results like fraud, it probably is fraud.....)

    By November 2012, defense is attempting, in collusion with applicant attorney #2, to effect a premature settlement, waiving all rights for return to work, future medical, social security, medicare and anything. No recommended treatments or further evaluations authorized. $80k out the door, go off and die under a bridge for all anybody cares about you as an injured worker.

    Applicant attorney was summarily dismissed after the aborted deposition that resulted in the 'settlement' chicanery, in which he said, "nobody will ever believe you have a brain injury, if you don't accept this, you'll get nothing."

    He didn't seem to grasp that his incompetent failure to get medical treatment for me in the first year was a problem, and that I am injured, not stupid.

    The QME/AME doctors minimize the injuries and call it a 'headache' and being over age 35, and female. What kind of system would prevent an injured worker from returning to work for a 1,000 day headache? Yeah.

    Now, 2 years, 6 months and several days later, finally, some good news.

    A UR RFA for 6 months of day-treatment for TBI was requested, and a verbal 3 months was approved, but the written approval was 1 month.

    I'll take what I can get at this point, then return to work as soon as possible, and get some on-going real medical help with employee benefits insurance, without the terrorism of the suits and white coats and black robes, so to speak.



    David, it's a Grancell case, they moved it to Novato. Wish me a Legion of Angels to protect me, huh?

    We're fed up with Americans Maiming and Killlng Injured Americans FOR PROFIT.... of primarily the #WorkComp insurance industries, and it's human drones.

    Tell your friends and neighbors; your governments already know.


  3. David! Look how much the CNA CEO makes off the maiming and killing of American Injured Workers?

    Is there a problem here? Anybody else able to connect these dots??? Grrrrrr. Now I am reallly mad. Check out the CEO of CNA!

    CNA chief Motamed a $10 million exec again @CrainsChicago and denies #WyndhamWorldwide injured workers medical...WTF http://fw.to/8cZKHPe

    How much does this guy profit? Dave North CEO of Sedgwick CMS

    "We legalize torture one claim denial at a time...."

    Ought to be some RICO investigations! Ought to be a national class action by and on behalf of injured American workers, imho.

  4. Lucy, it is always about the money. Since what starts in the West goes East, then we need the feds to come in here in CA. I've been in the system since 1988 and it has gotten much worse, if that is even humanely possible. More insurance CEO's & middleman who are pro business (selfinsured), more profit and even less for injured as THE decades go by. As I stated many years ago, injuring workers became a cottage industry. Workers comp ilk live off of injured workers so the more injured workers, the better. There should be no litigation, that was part of the deal (medical care, wages and be made whole-Federal Mandate in early 1900's industrial age) with labor & industry who founded worker's compensation in lieu of tort claims.
    How about a R.I.C.O. since insurance money is spent on things, funneled for other reasons. And don't forget t to include, of course, those who help keep that money rolling in and taking part of that money, like judges, attorneys, doctors, the whole of WC ilk.
    We as once being a productive worker are nothing more than an ATM machine for a particular group of folks. Our claims #'s with it;s stated amount of benefits prove it.That's not only sick, evil BUT a giant scourge on humanity. TO think it happens in the U.S.A is incredulous.
    How about Injured Workers, INVISIBLE NO MORE!


  6. Experiencing back pain is really a tough ordeal, especially if it's due to previous medical conditions. Therapies must be scheduled and medications must be prescribed. I believe workers have the right to be provided with ways of dealing with those things, and shouldn't be worn down by the burden of costs. That's why insurance provided by employers is really something we should all be thankful for.

    Mitchell Carlson @ InsureYourCompany.com