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Fallguy

Denial process

39 posts in this topic

A claim would be accepted waaayyyyy before the injured worker has reached MMI. There isn't a set time when the claim might be deemed compensable. IT can take time to get the applicable medicals, and investigate the claim.

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I don’t think there was any investigation. The adjuster denied it as soon as he was assigned to my claim. He said I didn’t have medical support and no witness. He didn’t even bother to review the report or get statements from the other co-workers. The never got his denial letter either. 

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I would expect the adjuster to at least pick up the phone and call the doctor and ask  for the first report of injury. Was he overworked and forgot to call? Maybe. Perhaps he made a mistake and mixed up some files? Possible. When I brought this to his attention, he told me to go through the appeals process. What would be his reason to deny a claim with no medical support when it was available? Lastly, he also noted an unwitnessed accident. There were several co-workers there that day. 

    I don’t know the man so I’m sure it wasn’t personal. It’s possible he was under a lot of pressure from his managers and my claim was just the next one on his denial list. 

     This makes me wonder how often are claims denied without a good faith investigation and an injured worker doesn’t recieve the necessary treatments that they need. There’s not very many injured workers that can afford to go through 2-5 years of the appeals process. That’s a minimum estimate because I’m sure he would have notes to his files that he denies and all medical treatment will also be stretch out as far as he can stretch them.

    This is a very experience adjuster and he knows what he can and away with. He knows the workers compensation procedure as much as any attorney. An injure worker doesnt stand a chance. 

     I haven’t worked in every single company in this country but I can almost bet my last dollar that workers compensation is briefly explain during orientation or at the time of hire. I’ve worked in companies that doesn’t have orientation so it was never explain. The posters are usually in a hard to see corner. After working several years, nobody will remember much from orientation and the handbook is probably collecting dust if it’s not already in the trash. As employees, we put our trust in our employers that they will look out for our best interest. This would seem like an even trade since we work hard to bring them revenue.

      I hope that this is not a common occurrence in workers comp. I really do. Im glad that there are sites like this one that does raise awareness and educate the public who can’t afford an attorney. With that being said, it seems some of the experts here are somewhat on edge. I don’t know if it’s because “internet trolls” or people who may use these sites to commit fraud that has their guards up. I can see that that an expert can digest the facts and can point out holes in the questions. There are people that are more trusting and can open up. I was one of those people. This is still the Internet and I don’t know who is who on the other side. I left some details out in case the adjuster is on these boards too. The answer that would be, “if you haven’t done anything wrong then there is nothing to worry about.” That is all the reason an adjuster would need to send to the qme.

 

 I apologize if that was too long a post.

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This is about you 10th thread on this issue and you have really never given the details needed to help you overall.

 

1. When, where and how did the injury happen?

2. What was the injury?

3. When did you report it to your employer?

4. Did you see a Dr. ?

5. What did the Dr. say about the injury?

 

There will likely be more questions after you answer those.

 

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My apologies, ive had several different post. If your wondering why I am now asking questions after a year. It’s because I didn’t know that getting injured would change my life. When I finally got to see the qme, he listed my injury as industrial and he told me he would help me to recieve benefits. He schedule an mri and and I never heard from him again.

 

i slip and injured my back. It was reported that same day. I was out of work for a week and the doctor said lumbar sprain. I was terminated the day the doctor said I can return to with if there’s modified work. I never spoke to my employer after that and I sent the adjuster and email explaining what happened. I received an accepted letter a few days afterwards but said they wanted to investigate to see if there is loss wages.

 

  When I finally got to see the qme, he listed my injury as industrial and he told me he would help me to recieve benefits. He schedule an mri and and I never heard from him again.

       That’s when I started to research on the internet. I am told not that believe everything I see on the internet but I have met a few nice people that has been helpful, some who weren’t so welcoming but I’m sure everyone has their reasons.

      I’m not sure which site it was but I google, “why did it take qme five months to submit his report”. There was an article or another website that had a comment about it. It says that if the qme takes more than 30 days to submit his report then there’s a high chance that the adjuster sent him videos. It also said he will more than likely have an incomplete report. Goes on to say it’s a delay tactic from carrier. I know I shouldn’t believe everything I read or hear but everything that person said was true. 

    So I’m back to the beginning and scheduling to see another qme. 

 

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3 hours ago, PayrollHRGuy said:

You seem to have a problem following instructions. Read the questions I posted. Do not editorialize. I'm trying to help or at least to see if any help is possible.

 

Sorry, I will try again

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1. 2017, it occurred at my work place 

2. Lumbar sprain, bulging discs

3. Injury was reported within 30 min to an hour

4.saw doctor at ER, then doctor that was from their list of doctors

5. Doctor said lumbar sprain. Industrial injury and 16 therapy 

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4 hours ago, PayrollHRGuy said:

You seem to have a problem following instructions. Read the questions I posted. Do not editorialize. I'm trying to help or at least to see if any help is possible.

 

I have an even bigger question, one that got me banned from anothe forum. This could be the reason why i can’t find representation.

 

if your up for it, I can message you. I don’t want to be banned here too.

 

thanks 

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You were not banned from anywhere for asking that question. Assuming you even have a case I can easily imagine an attorney not taking your case when you can't answer the simplest questions as I asked them.  

 

Any private message you send me will be deleted unread.

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The substance of any workers case is how did the injury occur and did it result from the substance of your work.  All you said was you suffered a lumbar strain at your work place.  If you simply fell on the stairs at the office it would not be work related.  If you strained your back because your job required you to lift heavy weights it would be work related.  Although you have posted 66 times you have never given us any indication how your injury occurred and how it was work related.

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I slip on 

16 minutes ago, RetiredinVA said:

The substance of any workers case is how did the injury occur and did it result from the substance of your work.  All you said was you suffered a lumbar strain at your work place.  If you simply fell on the stairs at the office it would not be work related.  If you strained your back because your job required you to lift heavy weights it would be work related.  Although you have posted 66 times you have never given us any indication how your injury occurred and how it was work related.

I slipped on a wet floor

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Was the floor wet because of the nature of your employment or were you just walking on a floor that happened to be wet?  In other words, if you worked at a job where you were required to work in a wet environment, the fall might be job related.  If you fell on a wet floor in the lobby of your building it would not be.  

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Falling on a wet floor would be covered under WC, assuming it happened on the premises, while you were working, 99% of the time. Whether a bulging disk was related to the fall, and a week off work was reasonable, or whether a MRI was medically indicated and therefore should have been approved, totally different questions. There is an appeals process you have to follow if your claim is denied, or some aspect of your claim is denied, and you do not feel that it should be. Your adjuster is not going to do the leg work for you. Just like if you are in an auto accident and file a claim, the insurance adjuster isn't going to call the body shop to find out if your car is really damaged, or call your doctor to find out if you are injured. It is your responsibility to submit the information to justify the claim. The adjuster can also investigate if something doesn't add up, but if what they get from the start isn't sufficient, it is just going to be denied and you can appeal and submit the proper information needed as part of that appeal.

 

IF you didn't provide a witness statement, or medical support, the adjuster isn't going to go hunting for them. That isn't their job.

 

There is no requirement that WC be explained in orientation or at any point during employment. Posters are generally required, but that is all. The vast majority of employees never get hurt at work and never need this information so not every employer feels it is the best use of time to offer training on the process.

 

 

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There was minimal com

6 hours ago, ElleMD said:

Falling on a wet floor would be covered under WC, assuming it happened on the premises, while you were working, 99% of the time. Whether a bulging disk was related to the fall, and a week off work was reasonable, or whether a MRI was medically indicated and therefore should have been approved, totally different questions. There is an appeals process you have to follow if your claim is denied, or some aspect of your claim is denied, and you do not feel that it should be. Your adjuster is not going to do the leg work for you. Just like if you are in an auto accident and file a claim, the insurance adjuster isn't going to call the body shop to find out if your car is really damaged, or call your doctor to find out if you are injured. It is your responsibility to submit the information to justify the claim. The adjuster can also investigate if something doesn't add up, but if what they get from the start isn't sufficient, it is just going to be denied and you can appeal and submit the proper information needed as part of that appeal.

 

IF you didn't provide a witness statement, or medical support, the adjuster isn't going to go hunting for them. That isn't their job.

 

There is no requirement that WC be explained in orientation or at any point during employment. Posters are generally required, but that is all. The vast majority of employees never get hurt at work and never need this information so not every employer feels it is the best use of time to offer training on the process.

 

 

 I was terminated so i had very little communication with employer or IC. There were no explanation of benefits, no forms signed. 

   I was under the impression that adjusters had to investigate in good faith. I read on the Dwc website that adjuster needs legal evidence or medical evidence to support their denial. 

      I’m not quit sure what you mean by providing those evidence. Do you mean during the appeal? Or when the adjuster is investigating? Either way, doesn’t that leave the burden of proof on the injured worker? I’m not sure I agree with this. I can’t imagine an injured worker who just lost his job would have the time to go investigate and get witness statements. The doctor I saw was in their network. Unless he doesn’t want to get paid, I’m sure he faxed it to the carrier. 

      Why do I feel like the accused. Im not a doctor so i can’t tell you why I got a week off. I didn’t order the mri so I don’t have that answer either. I don’t slip into a hard floor daily so I couldn’t tell you if it can cause a bulging disc or not. I was jus answering what’s I saw on the mri report.

        I know accidents don’t happen everyday so spending all that time to explain would sound like a waste of time for the employer. I’m sure the employee would feel better if it was explained. Since accidents don’t happen everyday, why go to the extreme of denying it and forcing the injured worker into the long emotional roller coaster.

        I feel like this is an employer dominated board. Is it common to accused then help provide meaningful answers? I’m sure my writing is a little hard to understand but everyone who reads or write and interpret it differently. Not all minds are the same. Especially in writing, the true context can be lost. 

     If I was to commit fraud, I think the first thing I would have done is get an attorney. I would take pictures or get witness statements. If anyone was to commit fraud, I think they would have taken the first offer and not worry about their health in the future.

 

thanks for replying 

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You misunderstand how WC works. It is an insurance policy. Your employer has very little control over the claim. If you don't understand the process, you need to speak with the adjuster. That is who can explain what is happening.

 

The burden is on you, the person seeking benefits, to submit sufficient information to justify a claim. If you fail to do so, then yes, it is going to be denied for lack of information. The adjuster's job is to take the claim and evidence YOU submitted and make a determination as to whether or not the claim falls within the parameters of a viable WC claim under state law. If you disagree with their determination, you would file an appeal. This is not onerous. You received a letter or some communication stating why the claim was denied. Again, if you had questions, you needed to ask the adjuster who sent the letter. If you didn't understand how to file an appeal (though this is a pretty straightforward and easy task), hire an attorney to help you. Your state has an incredibly employee friendly website, offers free seminars for injured workers, and has folks who can answer your basic questions for free by phone. https://www.dir.ca.gov/dwc/InjuredWorker.htm

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I think we are swaying from the original question. I think my question might be a little confusing or i may have misunderstood your answer. 

       Let me try it again. My claim has been denied. I’ve provided 3-4 doctor report to the adjuster that my injury is industrial. That includes the qme’s initial report. That qme is no longer practicing but he managed to submit his supplemental report that was five months late. This was around the same time of the video was taken. I can’t prove it was sent to the qme but the adjuster continues to emphasize that he did not send it to the qme. That only raises my suspicion more and thats the reason I ask about it on another post. 

    I’ve provided everything that I can but the adjuster is not budging. I believe asking the adjuster who is not looking for my best interest will only hurt my claim. 

     Is my next step to file for a hearing and submit the medical evidence to the judge? Will the judge side with the Qme report? The report is poorly written or I should say not written. Its two sentences long. 

 

Thanks for replying

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The statement of the American that the 

48 minutes ago, Fallguy said:

I’ve provided 3-4 doctor report to the adjuster that my injury is industrial

The statement in the medical report that the injury is industrial is certainly not binding on the carrier.  It is not the function of the medical providers to determine whether the injury was job related or not.

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Your claim for lumbar injury is denied for no medical support. There are inconsistency in your report of an unwitnessed injury. Base on information we obtained good faith action are not compensation per lc 3208.3

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