QME findings

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Latest post 10-21-2009 10:15 AM by stevepsca. 1 replies.
  • 10-20-2009 11:17 PM

    • aangie
    • Not Ranked
    • Joined on 05-16-2008
    • Posts 9

    QME findings

    I went to QME after bing denied for a knee injury claim. All my doctors I have seen have told me I need a total knee replacement. Anyhow after seeing the QME he has concluded that this is an industrial injury, there may be an apportionment factor due to the fact I had an injury as a teenager which never required any treatment. He stated that my sudden onset of problems (pain, difficulty walking, difficulty sleeping and driving due to severe pain in my knee that travels into my ankle and hip).are all industrial.

    Anyhow once he has determined it is industrial when can I seek treatment? I need to see a ortho MD and have asked the claim adjuster for an auth to see a Dr. of my choice and they are putting me off.

    Last year I also had 2 claims that were 100% work related and I was told I had an 8% total body disability. So far I have handled everything on my own without legal assistance but I think I'll probobly need to get a lawyer sometime soon as we have not settled. I am back at work from my injuries last year and am having alot of pain and difficulties performing due to my latest injury and my employer, I believe is trying to find reasons to get rid of me.i really need the auth to see a Dr. soon so I can keep my job and medical insurance. Can a employer make you pay cobra premioums when out on a work comp injury? I understand they probobly can after 4 months but can they do it right away?

    Thank you for your assistance I understand you all are not lawyers I'm just looking for direction.

    Thank you again

    Angie

  • 10-21-2009 10:15 AM In reply to

    Re: QME findings

    You have quite a few issues crammed into one post...

    Once you file a First Report Of Injury with your employER, you are to be provided with information on how to select a PTP in the carriers MPN/network. IF that is not done appropriatly, you can treat with a physican of your choice. There are numerous rules, and cases on this issue. Some going back to at time of employment info you were to be provided regarding industrial injury. Thats another matter however.

    You have a PTP, presumably in the ICs MPN. You must remain treating with that doctor unless you are eligible for a change. You are permitted to change PTP, in the MPN up to 3 times. Just call a doctor, make an appt, and notify the CA/claims adj, of your selection of PTP. You do not need prior authorization to do this. You say you are requesting to see a Dr of your choice...(?)  Any doctor you select must be in the MPN. The IC is permitted to control medical treatment and costs by using the MPN and ACOEM/MTUS treatment guides, and UR/Utilization Review process.

    FEW exceptions would permit you to treat outside the MPN.  Difficult... not impossible.

    As you have a PQME report now that says 'yes' to AOE/COE, that your indury is industria l, the ER/IC  must begin payment of benefits, medical treatment, TTD etc, or file a DOR/Declaration Of Readiness to proceed to a hearing on the disputed issue. If that happens, the IC can be liable for your atty fees.

    If you are to be taken off your job, and are eligible for FMLA you should request that now. FMLA protects your job and ER provided benefits up to 12 weeks per year. Any contribution you pay for health ins you would still be responsible for. COBRA must be offered once the FMLA ends There is no 4 month rule.

    FMLA and WC are not related, though there can be some overlaps in the rules. Filing a claim for WC benefits does not provide job protection. Beyond the 12weeks FMLA rules, your ER is free to sever your relationship, within the comp rules.

    As to your prior claims... IF you have permenant disability/impairment due to this injury, ie 40% WPI/Whole Person Impairment, the 8%, and any other pre exsisting issues that contribute to causation of PD will reduce the new rating. Your WPI would be reduced to 32% for PD due to this injury.

    You say you have not resolved the prior claims...if you disagree with the PD/WPI 8% finding, you can request a Panel QME to re-evaluate that decision. Has this current issue/claim been determined as ''new injury'', or compensable consequence to the prior unresolved injury/claim. You could see that happen here.

    Due to the questions you are posing here.... and your appearant lack of understanding and knowledge of the WC system/rules/process... I think it would be a real good idea if  you were to consult with an attorney or two... and/or Information & Assistance officer at the WCAB.

    Information you receive on a message board should not be a substitute for valid legal advice. An attorney is necessary to protect your best interests, and ensure you receive the benefits you are eligivle for. There is no consultation fee, and if there is an award/settlement a judge would have to order any fees paid.

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