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Injured 9/27/12 of my neck. A dr sugg Sx. Wkmen comp sugg IME. Can I file a utilization Review?

East Stroudsburg, PA |

I injured my neck at work 9/27/12 since then I've been on wkmen comp and was diagnosed with severe case of cervicle spondylosis. After 90 days of a treatment plan which has failed. I went to another dr and he advices Sx. My ins said to cx surgery and see IME. The problem I have I'm in alot of pain and nothing has been wking. I called an atty office to seek council but the paralegal stated wkcomp has the right and I hv to go. What is the process of filing a utilization review and do I need an atty for this.

Attorney Answers 7

Posted

The short answer is yes, you need an attorney. ASAP. The consultation will likely be free. Make an appointment right away.

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Posted

The carrier has a right to a pre surgical IME. You can get a prospective UR but that only determines the reasonableness and necessity of the treatment. It does not deal with causal relation. You need to retain a lawyer.

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2 lawyers agree

Posted

I agree with James and Levi.

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Posted

Initially, you should not be excepting legal advice over the phone, especially from a paralegal. Given your situation, it is recommended that you contact and Attorney who is experienced in handling Pennsylvania Workers Compensation Claims for an initial consultation to discuss your rights and obligations pursuant to the Pennsylvania Workers Compensation Act. Most Attorneys will not charge for an initial consultation and will except your claim on a Contention taxicab basis Pierde assuming you are currently receiving Workers Compensation Benefits, typically there would be no charge for representation until a Petition is filed by the Worker's Compensation Carrier.
I take a much different position regarding the Workers Compensation subcarriers entitlement to and Independent Medical Examination. Factors going into whether or not the Defendant is entitled to such an examination Include whether or not the employer actually have the right to control your medical treatment for the initial 90 days.

Although you can file a prospective request for capitalization Review, this process can take quite some time and it would be best to discuss this situation with an attorney.
Http://www.phillyworkinjury.com

This answer to your legal inquiry is based upon the limited facts stated in your question. Accurate legal advice is based upon an exchange between a lawyer and a client. The lawyer can then ask about other facts that may change or confirm the answer. Without that exchange, this reply should be considered limited in value. You should rely on this answer only at your own risk. Direct consultation with a lawyer is always recommended. Answering your question does not create an attorney-client relationship. The answering attorney is licensed in Pennsylvania and all answers are given pursuant to Pennsylvania law, unless otherwise indicated. If you have further questions regarding your issue, or my answer you may contact me to discuss this issue further by calling 215-496-9607 or sending an email to rjaffe@phillyworkinjury.com

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3 comments

Timothy D. Belt

Timothy D. Belt

Posted

I really want to agree, but there are just too many typos for me to be sure.

Asker

Posted

I'm sorry can't see my previous post. My question is now they rescheduled my IME to an indefinite date all do to the caseworker giving me wrong address. Either way my question is can I still have my surgery even before the IME is sched. I did sched a 2nd opinion with another orthopedic surgeon on 3/18. I postponed the surgery date for 3/28

Richard Alan Jaffe

Richard Alan Jaffe

Posted

You have many options and a lot Options at this point that do not involve the insurance carrier getting a IME before the surgery is performed. As I previously advised, it is imperative that you consult with an experienced Workers Compensation Attorney who can provide you with Advice regarding your situation, and file the appropriate Petitions and/or Requests for Utilization Review. I disagree with some of the answers that the Workers Compensation Carrier has a right to an IME at this point in order to prevent you from undergoing the surgery that has been recommended by your orthopedic surgeon.

Posted

I do not agree that the carrier is entitled to a pre-surgical IME. Depending on the facts of your case, they may be entitled to an IME, but I would not allow it to prevent or delay the surgery if you want it. You need to consult with an experienced Workers Comp attorney as soon as possible.

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2 comments

Asker

Posted

Are you saying with only legal representation would be the only way I can push for the surgery before the IME is scheduled

Geoffrey Hillsberg

Geoffrey Hillsberg

Posted

In theory, No. If you have alternative health insurance, you can push ahead with the surgery. If WC denies the bills, you can have your alternative insurance pay for the surgery and then fight to have WC reimburse the carrier for the bills. However, it is not simple and you will be far more likely yo have success if you have a good attorney.

Posted

I agree with Mr. Wolf, who is, by the way, an excellent attorney. You should contact an attorney immediately before you do anything else. That attorney can advise you moving forward and help to ascertain your next steps. The independent in Independent Medical Examination, rarely really means independent. So while you might be required to have one, you might want to take some other steps as well. Workers' Comp cases are handled on a contingent fee basis and the consultation should be free.

For a free consultation related to medical malpractice, personal injury, workers' compensation, social security disability or nursing home abuse, please contact Lowenthal & Abrams, PC at 1-800-876-5299. I am licensed in Pennsylvania, but members of my firm are licensed in Pennsylvania, New Jersey and New York. This post is not legal advice, but instead contains general educational information. Please do not act or refrain from acting based upon what you read in this post. Also please remember that this post does not form an attorney/client relationship between you and me. If you have specific legal questions, you should contact an attorney in your state for assistance. I am licensed to practice law in the state of Pennsylvania.

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Posted

The carrier is entitled to an IME at reasonable intervals, but they are not entitled to cancel surgery until you undergo the IME. Furthermore, although I do not have a crystal ball handy, I can all but guarantee the IME will find the surgery to be inappropriate in regard to your injury and this will then supply the insurance company with a medical opinion to fight against the surgery. If you want to have the surgery and your doctor thinks it is a good idea, I see no reason to wait until after the IME.

I would agree with the other posters that an attorney is a good idea especially since it appears that you are going to have a fight on your hands.

Timothy D. Belt, Esquire Helping injured workers in Northeast Pennsylvania. belt-law@belt-law.com www.belt-law.com DISCLAIMER: This post is intended as general information applicable only to the state of Pennsylvania. The information given is based strictly upon the facts provided. This post is not intended to create an attorney client relationship, or to provide any specific guarantee of confidentiality.

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11 comments

Asker

Posted

Since I do want the surgery. I am going for a 2nd opinion for myself. I think having two doctors will help me. If the 2nd doctor agree how do I go about getting the surgery. The IME had to be resched caseworker gave me wrong address.

Timothy D. Belt

Timothy D. Belt

Posted

Just have your doctor schedule it. If you have private insurance, you may want to provide this information to your doctor in addition to the workers' compensation as a back up if the workers' compensation insurance refuses payment. If the workers' compensation carrier tries to cancel the surgery or refuses payment, you have a bases for a Petition for Penalties.

Asker

Posted

Thank you so much. I can't take this pain and as the dr stated the longer I wait the more nerve damage that is irreversible even with surgery. Thank you for your prompt response.

Timothy D. Belt

Timothy D. Belt

Posted

Any time. And if you have any further problems, my office is less than an hour away. In fact, I will be at a hearing in Tannersville Monday, so feel free to contact me.

Asker

Posted

I thought you personal health insurance would decline just because you are under Worksmen comp insurance?

Richard Alan Jaffe

Richard Alan Jaffe

Posted

If you have private health insurance, it can be utilized as a secondary form of insurance if the primary insurance, the Workers Compensation Carrier declines to pay for the surgery. Once the surgery has been performed, and found to be reasonable and necessary, your private health insurance carrier can secure reimbursement of its costs from the Worker's Comp. Carrier

Timothy D. Belt

Timothy D. Belt

Posted

Right. Once workers' compensation refuses payment, your private health insurance is required to pay.

Asker

Posted

Would I be responsible for any balance from my personal insurance and can I go after Worksmen comp for it.

Timothy D. Belt

Timothy D. Belt

Posted

Your private insurance would work the way it normally does, so if there is a co-pay, that would not change. If you pay that amount, keep a receipt for reimbursement by workers' compensation. If I were handling it, I would file a Petition for Penalties and submit either the bill and the receipt into evidence as well as your testimony and seek reimbursement plus penalties from the carrier.

Asker

Posted

Point taken. Well, I do appreciate your time. I do have your name in mind. First I'm going to check how much is my co-pay is and speak to a rep on my personal health insurance to see how much they cover. If I run into a problem I will definitely call you to take the next step.

Timothy D. Belt

Timothy D. Belt

Posted

You may also be able to make minimum payments on the co-payment, so keep that in mind.

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