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Fallguy

Accepted claim

16 posts in this topic

I’m back with one last question that will make a big impact on my claim. 

 

This question is regarding my workers comp claim in California. 

 

Here is a quick overview. I slip on a wet floor in the break room and I was terminated the day the doctor release me on light duty. I was never offer any light duty work. The reason was for misconduct for something that happen over a month before date of injury. My claim was denied completely.

    I am now being told that my claim has been accepted but I’m not entitled to ttd because I collected sdi and I was already compensated. I was told that if they paid me ttd then I would have collected twice for same span. 

   My argument was that I should be entitled to the difference since sdi paid at a lower amount and they use income from a different date. They said it’s not correct but there are times that they have paid the difference if the injured workers wants to settle.

     This case from a person who is supposed to be neutral. Why would a neutral person try to convince me to take a nuisance settlement. It sounds like the carrier wants to avoid the lein by getting me to agree. 

 

Ellmd? Payroll guy... I need some assistance 

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7 hours ago, PayrollHRGuy said:

Get a lawyer.

 

 

Its not gonna happen. I stumble into the hub of workers comp attorney and most them are in bed with the carrier. My only chance is an out of state attorney

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1 hour ago, doucar said:

What do you  mean by "in bed with your carrier?" It is hard to believe that there is not one attorney in California who couldn't properly represent you.

 

There are quite a few so I’m sure someone will. The problem is finding who is who. If they’re st the bottom of totem pole, you be lucky to get a nuisances settlement. 

 

   The ones that decline my case are usually the names that pops up when you google workers comp attorney. I read somewhere that attorneys are far to busy to tend to every client. This is not true, at least in my city. I’m sure everyone is in each other’s contact list.

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8 hours ago, PayrollHRGuy said:

That is simply not true. I would think that it is much more likely that if WC lawyers aren't choosing to represent you it is something you are saying or not saying during the call.

 

Have you tried calling recently? I can assure you that the calls are being answered by the attorneys assistant. They all screen the call in similar order. You would have a better chance winning the lottery than speaking to the attorney. They write down name and info, then they look up your case in the system. After that, if it’s something they choose to take, you will get a return call. Now if you are somehow lucky enough to get an assistant who’s aggressive in setting appointments, you will get an appointment. The appointment will not be with the attorney, it will be with the assistant. Sometimes, they will call you before your appointment and cancel because the attorney recognizes your case and doesn’t want to bother.

 

payrollguy, is this standard practice or did I imagine this? Trust me, I called so many that I could probably get a job setting appointments.

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1 hour ago, PayrollHRGuy said:

Standard practice is for WC lawyers to have free consultations with injured employees.  I have no doubt you are saying something on the phone that is creeping them.

 

 

Thats pretty funny.....you can come up with something better than that.

 

You haven’t provided any context to support your statements. If that makes you feel better, I guess you can say whatever you want. 

 

I’m not the expert here so I doubt anyone would care about my character. 

 

 

 

 

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As I understand your situation, your claim has been accepted but the WC insurer is setting off your income from other disability income.  They have the perfect rightto do that.  You can only recover the difference between the other disability insurance and the comp payment.  How much money would that amount to?  It may be the amount at issue is not enough to interest the lawyers you are contacting.

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Once again, you only give me part of the information needed to answer your question. A claim being accepted does not mean that the lost time is accepted. Meaning, they can accept that you fell. They can accept that you might even have had an injury from the fall. They can still deny that the reason you had to be off work was because of that injury or fall, or that you really needed to be off work at all.

 

Frankly, you re in an incredibly claimant friendly state for WC. If you can't find an attorney willing to represent you, that should tell you a whole lot. Representing comp claims is sort of like shooting fish in a barrel. That goes double if the employer/insurer is looking to settle with indemnity. Basically, it is a guaranteed paycheck for very minimal work. Something isn't adding up.

 

That aside, You can't be double paid for the same injury time. Assuming, which has yet to be determined, the IC has agreed to some period of TTD and not just a "global" settlement ("we'll pay you $500 to cover medicals and lost time" with no set time period agreed to or stipulated) there would be an offset from disability payments.

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9 hours ago, ElleMD said:

Once again, you only give me part of the information needed to answer your question. A claim being accepted does not mean that the lost time is accepted. Meaning, they can accept that you fell. They can accept that you might even have had an injury from the fall. They can still deny that the reason you had to be off work was because of that injury or fall, or that you really needed to be off work at all.

 

Frankly, you re in an incredibly claimant friendly state for WC. If you can't find an attorney willing to represent you, that should tell you a whole lot. Representing comp claims is sort of like shooting fish in a barrel. That goes double if the employer/insurer is looking to settle with indemnity. Basically, it is a guaranteed paycheck for very minimal work. Something isn't adding up.

 

That aside, You can't be double paid for the same injury time. Assuming, which has yet to be determined, the IC has agreed to some period of TTD and not just a "global" settlement ("we'll pay you $500 to cover medicals and lost time" with no set time period agreed to or stipulated) there would be an offset from disability payments.

 

I would like to give details but it wouldn’t change much. I don’t know if you will be willing to give me any feedback. I do believe that you would know what steps I need to take so the carrier doesn’t delay any further.

    My case is at the stage that the only thing the carrier can do now is delay benefits. 

 

       It’s not that I can’t find representation. I’m sure someone will take it but I’ve decided that I will not use anyone that has ties to the carrier. I want an attorney who will fight for injured workers. I’ve seen  enough to know that there are many types of attorneys. Some just goes with the flow and accepts more cases than they can handle because more cases equal more money. Then there are those that really look into the details of the case and actually applies laws to help the injured workers. 

   California may be a claimant friendly state but carriers and lawyers are 99.9% protected. All complaints against carriers goes through the audit process and its anonymous so you will never know if they were disciplined. All complaints for attorney goes through calbar and there’s a simple excuse they can use to avoid any malpractice. I forgot the term for it.

    I havnt done too bad by myself and to debunk the theory that my case is only worth $500. I can tell you that they have offered future medical and open medical if I want to settle. They also offered to settle with ppd and I turned down all three. 

      I don’t know much about the value of my claim but I have sales experience so I understand the negotiation process. I decline simply on the fact that they made those offer too easily. I’m curious to know the true value. If they are willing to hire an attorney and do a year of surveillance, there is something more than meets the eye. All this for a “fall”? How did a simple fall turn into using so much of the carriers money to deny a claim that was accepted?

   I really need your expertises ElleMd. Have you ever seen anything like this?

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I can tell you I have rarely seen anything like this, from your end. You have no idea what you are doing. At. All. And the moves you are making that you seem to think are so shrewd are basically only hurting you. You don't even know what it is you want but no matter what they have offered, you turn it down thinking you are somehow outsmarting them. Rest assured, you are not. You are just looking foolish. You refuse to hire anyone who actually does know what they are talking about because of paranoia that they are in cahoots with the IC is just plain daft. Unless you are calling defense attorneys, or the firm that literally represents the IC, they are not in on anything. The world of WC is a reasonably small one, not unlike other areas of law (only so many practice any one area of law in a given area) and yes, those who do tend to know one another. Contrary to what you see on TV, the defense bar and the claimants bar are not the Sharks and the Jets. There is often a collegiality among those who practice and that works to your benefit.

 

The benefits to which you might be entitled are pro-scripted by law. Your "sales acumen" doesn't change that. There is only so much negotiating you can do. You may well have have burned your bridges by playing games with them as long as you have.

 

Surveillance is far, far from uncommon and very frequently is done at various times over the course of a claim. Nothing at all unusual there. It isn't terribly expensive, particularly if done in house. The IC either has legal counsel on staff or on retainer and very nearly every case gets assigned to an attorney, so that is just run of the mill business practice too. You make vague mention of malpractice and violations by the IC, but nothing to indicate what those would be (and none of your posts even hint at anything other than you disagreeing with them denying your claim), nor that you ever even filed a credible complaint of any sort of violation to the appropriate regulatory body.

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On 11/5/2018 at 8:04 AM, ElleMD said:

I can tell you I have rarely seen anything like this, from your end. You have no idea what you are doing. At. All. And the moves you are making that you seem to think are so shrewd are basically only hurting you. You don't even know what it is you want but no matter what they have offered, you turn it down thinking you are somehow outsmarting them. Rest assured, you are not. You are just looking foolish. You refuse to hire anyone who actually does know what they are talking about because of paranoia that they are in cahoots with the IC is just plain daft. Unless you are calling defense attorneys, or the firm that literally represents the IC, they are not in on anything. The world of WC is a reasonably small one, not unlike other areas of law (only so many practice any one area of law in a given area) and yes, those who do tend to know one another. Contrary to what you see on TV, the defense bar and the claimants bar are not the Sharks and the Jets. There is often a collegiality among those who practice and that works to your benefit.

 

The benefits to which you might be entitled are pro-scripted by law. Your "sales acumen" doesn't change that. There is only so much negotiating you can do. You may well have have burned your bridges by playing games with them as long as you have.

 

Surveillance is far, far from uncommon and very frequently is done at various times over the course of a claim. Nothing at all unusual there. It isn't terribly expensive, particularly if done in house. The IC either has legal counsel on staff or on retainer and very nearly every case gets assigned to an attorney, so that is just run of the mill business practice too. You make vague mention of malpractice and violations by the IC, but nothing to indicate what those would be (and none of your posts even hint at anything other than you disagreeing with them denying your claim), nor that you ever even filed a credible complaint of any sort of violation to the appropriate regulatory body.

 

 

I couldn’t resist an opportunity to hear ElleMD expert opinion so I have to ask.

 

If ElleMD or anyone else who can explain how the adjuster can deny a claim without any legal or medical evidence to support the denial? They can also misused labor codes to deny your claim. (They can conveniently say they were over work and mixed up their work.)

    There is no entity or remedy for the injured worker other than an anonymous complaint through the wcab audit referral form. You will know if they were sanctioned.

       Why is it that attorneys, physicians, judges and adjusters can all use “I didn’t have all the information” to excused their actions? 

       I will agree with your statement that I have no idea what I am doing but everything else are just assumptions. Although rare, you can’t definitively say it has never happened before.

     Had it not been for my sales acumen, I would have taken their first nuisances offer. That offer increased three times within a week without a counter offer. You really need sales experience to know the basics but I became curious to know why the desperation and need settle so quickly. The very last offer included open medical and I decline because they have never once explained why or how they calculated the settlement amount.

       Some will say it’s paranoia but I call it “extra cautious”. I wouldn’t be in this position had I been cautious instead of trusting the WC system. 

       Here’s a little more facts I’ll share. The carrier does not have a standard procedure to notify their claimant that their claim has been accepted. All the while, they continued to deny benefits, hire private investigators for surveillance and strong arming you to take the settlement. 

      This is direct statement from the assistant chief of claims. I went to three level of management and everyone gave me a different answer to date that my claim was accepted. Two of them is still in denial and sticking to no benefits because I was terminated from my job. 

    The bottom line is, if you get injured and if the IC decides to make an example out of you. They will have an open book to ensure you are screwed. I’m sure they have in house counsel and possibly private investigator but one would think that would be a conflict of interest. I’m sure the investigation cost more then the settlement offer. I can say this because I’ve seen the video. The odds of the PI being at the right place at the right time is very small. 

    Let me add that I asked the adjuster and his manager several time if he made an error and cited the wrong labor code. He said if I’m not happy then I can take it to wcab. I’m sure it’s not the first time he fraudulent denied a claim. Otherwise he wouldn’t be as bold. 

    There’s is no end to this unless I walk away. Any awards would have to be approved by the judge so im sure there’s never going to be any penalties. The carrier can delay until their account is empty. They have change counsel, already sabatoge the second qme appointment. That means they’ve already prepared for the third panel or they know the judge will allow non medical records that I never received and sent well beyond 20 days of the appointment. I didn’t even get a chance to review those records.

 

ElleMd, if you can explain why the carrier can deny a claim for any reason they choose without any justification, I will recant my statement of corruption in the WC system.

    

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If you want me to explain why someone I have never met did something you have not fully explained nor given me the full story regarding, you are out of luck. I'm good, but I'm not psychic. Crystal ball is busted. I can only offer generalities as you have only offered the most random of details about your situation, in a very scattershot fashion no less.

 

A claim may be formally accepted in any number of ways. You might get a letter, a phone call, or email. Claims do not have to be accepted in whole. The IC can accept certain bills and not others. It can accept parts of the claim and not others. For example, it can accept that an incident happened, but deny medical treatment and lost time beyond the initial evaluation. They could accept that you injured your knee but not your back and so deny lost time and or medical treatment to your back. They could accept that you hurt your right arm and authorize 6 PT treatments, but not more than that and deny a cortisone injection.

If you disagree with the denial of any part of your claim you have to file an appeal. You can't call them up and negotiate a compromise. Carriers can't just deny claims because their magic 8 ball tells them to, or whatever arbitrary reason you seem to think they would do so. Whatever the reason, if you disagree, you must file an appeal within the time frame allowed to do so and it will be adjudicated. I have no idea why you are so bent on ICs wanting to deny clearly meritorious claims simply to incur the significant added expense of defense.

 

If it appears that you might appeal some aspect of the claim, and it the claim meets certain other internally identified criteria, sending it to counsel and for surveillance is routine. You don't have to do a thing. It is not at all in any way a conflict of interest. This is standard practice.

 

Settlements happen for more reasons than can be listed, as explained previously. There are also numerous types of settlements and you would be wise to consult a lawyer before settling anything as they are legally binding.

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4 hours ago, ElleMD said:

If you want me to explain why someone I have never met did something you have not fully explained nor given me the full story regarding, you are out of luck. I'm good, but I'm not psychic. Crystal ball is busted. I can only offer generalities as you have only offered the most random of details about your situation, in a very scattershot fashion no less.

 

A claim may be formally accepted in any number of ways. You might get a letter, a phone call, or email. Claims do not have to be accepted in whole. The IC can accept certain bills and not others. It can accept parts of the claim and not others. For example, it can accept that an incident happened, but deny medical treatment and lost time beyond the initial evaluation. They could accept that you injured your knee but not your back and so deny lost time and or medical treatment to your back. They could accept that you hurt your right arm and authorize 6 PT treatments, but not more than that and deny a cortisone injection.

If you disagree with the denial of any part of your claim you have to file an appeal. You can't call them up and negotiate a compromise. Carriers can't just deny claims because their magic 8 ball tells them to, or whatever arbitrary reason you seem to think they would do so. Whatever the reason, if you disagree, you must file an appeal within the time frame allowed to do so and it will be adjudicated. I have no idea why you are so bent on ICs wanting to deny clearly meritorious claims simply to incur the significant added expense of defense.

 

If it appears that you might appeal some aspect of the claim, and it the claim meets certain other internally identified criteria, sending it to counsel and for surveillance is routine. You don't have to do a thing. It is not at all in any way a conflict of interest. This is standard practice.

 

Settlements happen for more reasons than can be listed, as explained previously. There are also numerous types of settlements and you would be wise to consult a lawyer before settling anything as they are legally binding.

 

 

Sounds fair enough. I’ll break it down to important events so hopefully you can make some sense out of this mess. I would really be thankful and my mind could use a break.

 

i will used estimate dates so there’s no confusion:

 

1-1-17-doi slip on wet floor. The manager reported it to HR, I went to ER, I was out a about 7-8 days

 

1-10-17- went to doctor from list that was provided. Dr reports as industrial and modified work.

 

1-13-17- went to work to show dr note. I was terminated for misconduct that was from 12-1-16.

 

1-21-17- received denial for no witness or medical evidence. Also states that my injury is Not covered by LC 3208.3. They don’t good faith personal injury.

 

6-1-17- qme- reports industrial and modified duty- and mri.

 

8-1-17-mri appointment 

 

2-1-18- supplement report says nothing’s change and mmi date is 8-1-17. He retires and haven’t heard from him since.

 

 

sdi was effective 1-10-17

 

ptp- has ttd since doi

 

last week, I went to hearing for ttd. Judge couldn’t decide so wait for results of qme appointment. I overheard their attorney tell the judge that my claim is accepted. I received Acceptance letter. 

 

3 days later, received denial again. Says we accept dr report of dates and ttd but ttd denied for termination of caused.

 

Next qme appointment is next week

the dates are not exact and I left out all the crazy things the adjuster did in between. 

 

Hope this helps

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