Friday, July 25, 2014

Restoring Faith

So far there have been 27 comments in the Workers' Compensation Roundtable LinkedIn Group following my post about my work "injury."

That was just one work comp group and happened to be the most prolific. Plenty of other comments have been made in other venues.

I never in my wildest dreams would have imagined that my little, slightly sarcastic, muse on being both an employee and employer dealing with the same work injury and ultimately deciding that work comp was the worst of all worlds for dealing with it would create such interest, controversy, engagement and interaction.

But it did.

Some disputed that it could be labeled industrial since it was only a back sprain. Others said to stay out of the work comp system at all costs. And others simply demonstrated a lack of understanding of work comp, at least relative to California law.

No one, though, said that I should file a claim as an employee or report the claim as an employer.

Perhaps that's because everyone is a professional in the system, an insider, and everyone knows that once a claim comes into the system both the employer and the employee lose control to the gaming that every single vendor - insurance company, doctor, lawyer, etc. - will engage in to "do the right thing" according to their special interest.

Certainly there were more "claim denied" or "services denied" responses than I thought would occur.

Just like real life work comp.
Bowzer lost faith
The California Workers' Compensation Appeals Board on Thursday designated a case a "Significant Panel Opinion" because a carrier that had approved nurse case manager services prior to SB 863 unilaterally, and without legal authority, terminated those services because there had been no Utilization Review or Independent Medical Review.

In Patterson v. The Oaks Farm, No. ADJ3905924, Jennifer Patterson had worked as a horse trainer for The Oaks Farm. She suffered serious injuries to her head, neck and spine in 1999 when the horse she was riding tripped and threw her before falling on her and pinning her to a fence.

The Oaks carried workers' compensation coverage through the California Compensation Insurance Co., but the carrier went insolvent in 2003. The California Insurance Guarantee Association then assumed its liabilities.

CIGA and Patterson both stipulated to having Dr. Randolph Noble serve as the agreed medical evaluator for Patterson's workers' compensation claim.

In 2011, Dr. Noble determined that Patterson required nurse case manager services. CIGA initially authorized and provided her with a nurse case manager, but later unilaterally terminated the service.

At an expedited hearing on the issue, the judge found that Patterson's condition had not changed, and so the discontinuation of her nurse case manager services was not warranted. The judge ordered CIGA to resume the provision of nurse case manager services, and CIGA appealed.

A unanimous three member panel denied the appeal.

Newly appointed commissioner, Katherine A. Zalewski, wrote for the panel that an employer or carrier cannot unilaterally cease to provide approved nurse case manager services when there is no evidence of a change in the employee's circumstances or condition showing that the services are no longer reasonably required to cure or relieve the injured worker from the effects of her industrial injury.

Ergo, without such evidence, a carrier can't just stop providing treatment services.

Experts interviewed by WorkCompCentral for this morning's story on the case opined that they weren't sure why this was cited as a Significant Panel opinion because the case simply reiterates what has been long standing law in California - that medical treatment can't be unilaterally terminated.

Richard Jacobsmeyer, founding partner of workers’ compensation defense firm Shaw, Jacobsmeyer, Crain & Claffey in Oakland, said that perhaps the notion that case management is deemed "treatment" as opposed to optional services is what the Board was getting at by designating the case as Significant.

But based on the comments and reactions to my posting about my work injury, I think it comes down to basic education, and a realization by the WCAB that Patterson's plight isn't all that unique; that there is far more delay, denial and obstruction to benefits, particularly if there is any "gray" in a case, than is legally, socially and morally allowed.

Particularly when there really isn't any real threat of penalty, sanction or discipline for doing so.

For those of you that aren't familiar with California law, if I was at work and doing work when an injury occurs, then it's workers' compensation regardless of whether the condition is idiopathic or was pre-existing.

You can't apportion the need for medical treatment in California - even less than 1% of industrial causation is enough to invoke the provision of benefits.

That's the law and that's just the way it is.

But based on the comments to my original injury post, there are few that are willing to accept or recognize that reality, and consequently no one has any trust in the system.

And maybe the WCAB in Patterson knows that, and is trying to restore faith in the system.

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