Asked almost 2 years ago - Lancaster, PAFlag
I live and work in PA. In November of last year I suffered a fall at work and have had PCS since that time. I notified my work within a day and saw a provider through the worker's compensation network. The WC doc told me to play the wait and see game and closed my case. I reopened it about 1 month ago, as trying to focus at work has become overwhelming - not painful, just exhausting and very uncomfortable. He is saying that these symptoms are not from the accident, which is untrue as they have been ongoing. He is the only doc, though, that I have seen for this. What is my recourse? My family doc does not deal in WC issues, so I would have to see a doc who does not know me. It's hard to imagine them releasing me from work, as I look OK. I can not learn a new job now either. WTD?
You may very well have a workers' compensation case. You should certainly seek out treatment with a doctor off the panel. You are only required to treat with the panel for the first 90 days and you are beyond that point. Your family doctor would be a good place to start. He knows your past medical history and could make an initial record then refer you to a doctor that does handle workers' compensation cases. You may also want to see a workers' compensation lawyer who could provide you with further guidance based upon your specific facts.
I agree with Timothy. You are only obligated to treat with a panel phsyician for the first 90 days (and even that much if the employer has complied with the requirements - many do not). The family doctor, having known you before the injury, really is in the best position to know what is or is not related to the work injury. Though I know some doctors do not like handling cases with litigation, such as workers' comp cases, many will do so if their patients need the doctor to have a case.
Glenn C. Neiman
Brilliant & Neiman LLC
Another problem you may have is a practical one. If you go to any doctor and tell them your condition is related to a work injury, they have to submit the bills to the applicable worker's compensation insurance carrier. Many times the doctor's office will call the carrier for "pre-approval". If the doctor is not a panel doctor, even if more than 90 days have elapsed, the carrier will very likely refuse to pre authorize the treatment. (they are never under any obligation to do so) If this happens the doctor may not treat your or you may not be able to get the diagnostic studies, such as an EGG or MRI that the doctor may try to order. If this happens, you must get to a lawyer.
Mike's concern is easily remedied. Give any provider your WC number as your primary insurance. Give them you health insurace as secondary insurance. Instruct them to bill WC first. They must bill WC first, Then, if WC denies the bill, they can send the bill and the denial to the personal health insurer (secondary) insurance. Under regulations issued by the Pa Insurance Department, the secondary insurer must pay and seek reimbursement form the WC carrier.
I agree you should start with your family doctor, but I think you need to see a specialist called a neuropsychologist. Neuorpsychologists adminsiter extensive cognitive testing to identify what cognitive deficits you may be suffering and define the nature of your head injury. At this stage, the labels traumatic brain injury (TBI) or mild brain injury (MBI) are probably more accurately than PCS.
You may want to research you condition on line. Start with the Pennsylvania Brain Injury Association.
Brain injury claims are very difficult. They are expensive. they invovle very complicatied and nuanced medical issues. When you seek legal advice, make sure the lawyers you interview have expereince with these kinds of cases. Look for a lawyer who has tried at least three brain injury cases before. They are not commonplace, so you won't find a lawyer who has tried 10s or hundreds.
Some employers do not seek to control or limit your choice of who
you treat with for your work injury. Others attempt to control this
choice, but can attempt to control your choice only during the first
ninety (90) days of treatment. Many employers and insurance
companies seek doctors who are willing to cooperate with their
wishes in return for a steady flow of patients. As a result, too often
your health interests become secondary, proper testing is not prescribed
to curb costs, you are misdiagnosed and are pressured to
return to work when you are not able to physically tolerate the job
duties. If you are subjected to this despicablemistreatment, do not
treat with the company doctors unless it is financially necessary;
get away from them as soon as possible. Failure to treat with the
company doctor is not a valid reason to deny a wage loss claim. For those employers seeking to control your choices, Pennsylvania
law requires the employer to provide several minimum safeguards
to protect you. If the employer provides a list of doctors it
wishes for an employee to treat with for the first ninety (90) days,
the employer must: Provide a list of at least six (6) health care providers. At least
three (3) must be physicians and no more than two may be coordinated
Not include on the list any health care provider who is employed,
owned or “controlled” by the employer or carrier unless
that information is disclosed; and
Provide you with and have you sign a written “Acknowledgment
of Rights and Duties” relating to treatment for a work injury
both before and after the work injury and a document stating that
you are NOT required to treat with only one specific provider.
Without these two signed documents, you can treat with whomever
you want and the carrier must pay if the treatment is found to be
work related. However, if you were presented with the Acknowledgment
before and after the injury and refused to sign, it will be
treated as if you did sign the Acknowledgment.
If the employer’s provider prescribes surgery, you are entitled
to a second opinion with a doctor of your own choosing within or
outside the panel list. In all cases, even when surgery is not
recommended, you are always free to switch among providers on
the list. If the list does not include a specialist, (for example, a chiropractor),
you desire to treat with, you are free to treat with that
specialist outside of the list and the carrier must pay if the treatment
is found to be work related.
If there is no panel list, you may treat with a doctor of your
choosing and the workers’ compensation carrier must pay for the
work related treatment. If the employer followed all of the rules
regarding the Acknowledgement of Rights and Duties and the posting
of the list, youmay treat with your own doctor at your own expense.
If the employer fails to abide by any of the above
requirements, the workers’ compensation carrier is responsible for
payment of your work related treatment during the first ninety (90)
days wherever you choose to treat. Regardless of whether or not
your employer followed the rules for posting and implementing a
panel list of physicians, after ninety (90) days, the workers’ compensation
carrier is responsible for all reasonable and necessary
treatment related to your injury wherever you choose to obtain the
treatment. Your treatment options are not even limited to this
country. Ultimatley, if there is a dispute as to what doctor's opinion is right, it is up to the workers' compesnation Judge to make that that determination.
For more information, go to www.workinjuryinpa.com
Although I am not licensed to practice law in your state, I would suggest getting a second opinion from your family doctor. I know you mentioned that your family doctor doesn't handle WC issues, but essentially what you need is a doctor (preferably) your family doctor to opine that there is a causal connection between your ongoing systems and your work-related injury. I think you should consult a worker's compensation attorney in your state for a legal consultation.
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