Is this a Workers Comp Denial?

Question

In March of 2007 my husband fell and sustained injuries to his miniscus. During a doctor visit he mentioned also having some numbness and tingling in his hands and some neck pain. The doctor told him this was not related to his injury and no further investigation was made.

Several months later the pain increased and he spoke to a workers comp lawyer to see what he could do and if his case was handled properly. The lawyer sent him to a neurologist and it was determined that yes it was very likely if not probable that this crushed disc in his spine was sustained in the fall. Surgeries followed and the healing process began.

In March of this year he had a hearing where the judge granted him pay up to the surgery and requested he see a doctor of the insurance company's choosing. Which he did. This doctor said in no way shape of form could this have happend in the fall. He went to a hearing today and was told the insurance company is standing by their experts opinion and

Answer 1

Your husband should get many second medical opinions in favor of of the injury being work-comp -related and he should keep careful record of them for the upcoming court date. He should request all medical records, reports, notes, and itemized bills from any doctor he sees. He should especially see a neurologist of his own choosing to counter the work comp's expert's claims. I wouldn't be surprised if their expert is biased.

Perhaps your husband can apply for disability?

Answer 2

Lots of good answers here, however any second opinions will have to be with your own money and they can be very very expensive. $2-3000.  As others have stated, at the onset of the injury, nothing was said about a back injury, you will have the burden of proof that the back problems were part of the initial injury.  You do not say what type of work your husband does and his age.  If he is a construction worker, say late 30's he probably already has herniated discs in his back.  Another problem is that almost every adult over the age of 25 has herniated discs in their back, and some neurologist will do surgery on anyone who comes to see them with herniated discs. .  I would also be suspicious if he allegedly had a "crushed disc" in his spine but was not bothered by this for several months.  If your husband hurt his back badly enough in this fall, and herniated a disc, or crushed a vertebrae, he would have had pain pretty quickly and pretty miserable pain too. It is possible he just has degenerative disc disease too.  But, even if the judge does not rule in your husband's favor, you can appeal to the appellate court,  However as another person indicated, it is a long process and he should either apply for disability or apply for some retraining thru your state to learn a different job.  Your husband should really try to get back to work, even if he wins his case, he will not get enough money live on for any long length of time.

Answer 3

No, this doesn't mean he's lost.  There's still a good chance he can win, especially if he has multiple doctors that say this was caused by the fall.

It's all up to the judge.

Answer 4

I used to work for a company that investigated workers comp claims.  The problem as I see it is that your husband's crushed disc was not diagnosed at the time of the fall, but only several months later.  In order to win this case he would have to prove that the fall caused the crushed disc, that he had no pre-existing back problems, that he'd engaged in no activity between the fall and the time of the claim that might have injured his back, etc.  This is very difficult if not impossible to do when this much time has passed.  

In addition you now have several doctors saying several different things.  I would suggest you get a lawyer involved in the case if you can, and as high-powered a lawyer as you can find, not some ambulance-chaser.  It's possible that if a lawyer gets involved a settlement might be offered.  Unless that happens, it seems to me it's going to be a long drawn out process of duelling doctors and conflicting testimony.

Answer 5

GallopingGrasshoppers is right...this is not the end of the line for your husband and his W/C claim.  If your husband has private or individual disability insurance, I would recommend following up w them to determine whether it would be beneficial to file a claim.  It should be noted that some plans cover work related disabilities, and some do not.  

If his plan does cover work related disabilities, then your husband's claim could be approved for the periods that he did not receive a benefit through W/C.  He will probably have to sign a reimbursement agreement w the insurance company allowing them to pay benefits, however if the W/C claim was ever overturned  then he would have to pay the insurance company back.

If the plan does not cover work related disabilities, then your husband's claim could be approved based off the W/C denial.  Again, he would probably have to sign the reimbursement agreement w the insurance company.

Either way, he should follow up w his private or individual disability insurance carrier if he has that coverage.  If he does not, then it will be up to the judge to determine his eligibility for W/C benefits.  He may also have statutory disability benefits he is eligible for...there are a few states that have this benefit.

Answer 6

Well the question is was he actually at work when the injury occurred?  Meniscus is in the knee so if his primary doctor who saw your husband said that it's now work related its all the work comp company needs to process a denial.  Granted they have every right because of the info provided.

Also you mention "several" months later, what happened in between the time from the injury to when you decided to pursue this?

So long story short, technically your hubby's claim is still denied but it's pending litigation, meaning it can change any time depending if the judge goes your way or the insurance way.  

Right now all you and your hubby can do is wait and see what happens.  This will be a long process.  Sorry.