I was awarded: a stipulation Award, that guarantees me, coverage, from my neck down to my feet

Asked almost 2 years ago - Oakland, CA

I had 6 surgeries, and I need 2/3 more. This is a W-Comp case ... I have a fractured thumb, and more torn meniscus tears, that require more surgeries. They have terminated my Health Benefits for no reason. What can I do, or does this type of action have a legal term for it

Attorney answers (3)

  1. Brett A. Borah

    Contributor Level 20

    3

    Lawyers agree

    Answered . An Award from neck to feet is unusual. Normally, an Award lists specific body parts....and there are a lot of body parts between neck and feet that may not have been injured. You need to look at your Award to determine exactly what body parts were included in the Award.

    What reason did they give for denying treatment? Not part of the Award? Not related to the injury? Not reasonable or necessary? Doctor making the request is not the primary doctor? Denied by utilization review?

    If you had an attorney, go back to that attorney. Either way, you may need to return to the evaluating doctor for his opinion on the treatment. You may need to go back to court for a trial on the issue.

  2. George Ellis Corson IV

    Contributor Level 20

    1

    Lawyer agrees

    Answered . Are you referring to terminating your WC treatment benefits, or terminating your Health Benefits at work because you failed to pay your Premium?

    We give free general concepts to be helpful, but you should give ALL your facts to a licensed Attorney in your... more
  3. Nancy J Wallace

    Contributor Level 14

    1

    Lawyer agrees

    Answered . Sadly, your Award on Stipulations does NOT 'guarantee' you a thing...except the right to battle in court for each requested procedure.

    Each time an MPN Treating PHysician writes out a 'Request For Authorization" the insurance company "UR" (Utilization Review) Doc will write that it won't help you or that more details are needed, and the request will be 'Non-Certified" (denied)...

    These denials usually continue until you request a hearing or the Panel QME writes you must have the requested procedure immediately.

    Private health insurance coverage is properly terminated when the insurance premiums are not paid... 'obamacare' in California is called PCIP, I'll pop in the website so you can apply for obamacare so it's a little more affordable.

    If you are trying to communicate that the Treating PHysician HAS issued Request for Authorization a procedure on a body part specifically listed on the Stipulations With Request For Award and there has been no response from the Insurer, then it's time for a Declaration of Readiness to Proceed for an Expedited Hearing.... and hope the WCAB Judge orders the procedure to be okay'd and paid.

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