I recently had a long and somewhat heated conversation with an insurance adjuster about body parts. Specifically, I wanted the adjuster to authorize medical treatment for my client’s neck and back , but the adjuster only wanted to authorize the treating physician to provide care for my client’s back.
As ridiculous as this may sound, this type of negotiation happens all the time in a workers compensation. Though common sense would tell you that an employee who injures his low back falling from an 8 foot ladder might reasonably be expected to suffer neck injuries as well (such as when his head hits a concrete floor), insurance companies are very careful not to assume anything.
The problem in my case arose from my client’s first conversation with the posted panel doctor. My client’s low back was in spasm and he was absolutely miserable, and he did not specifically mention any pain in his neck to the treating doctor.
I am thinking that my client had probably incurred a concussion and was not thinking straight in the first place so who knows what he told the company doctor. By the time I was retained, almost two months had passed and now my client is receiving epidurals for his lower back – although he may need surgery soon – but no treatment at all for his neck.
When my client goes to the workers’ comp. doctor and tries to talk about his neck pain, the doctor tells him that the insurance adjuster has not authorized treatment for the neck so the doctor will not treat the neck.
Imaging a doctor’s appointment where the physician tells you “I’m sorry you’re in pain but I am not allowed to treat that part of your body!”
My next move will be to request a hearing over the insurance company’s refusal to pay for cervical spine treatment. I suspect that when my hearing request gets to a defense lawyer, I will be able to work out some sort of compromise where the insurer will pay for an orthopedist to look at my client’s neck and if there is no evidence of any pre-existing problem, I expect that the insurance company will end up picking up the neck claim.
The takeaway from my client’s experience:
when taking to the workers compensation doctor, mention every part of your body that hurts even a little. Some injuries take a few days to reveal themselves.
if you start to experience pain a few days after that first visit, do not wait to try to update your injury report. A few days delay usually won’t hurt you but a few weeks or months might
you will benefit by talking to an experienced workers’ compensation lawyer sooner rather than later. I have represented clients and reviewed medical records for 20+ years. I can usually help my clients make a more thorough first report of injury and I can even help prepare them for their first few doctor’s visits.
insurance companies will take advantage of your lack of familiarity with the system. Insurance adjusters are paid to save money not to help you get better
delays in treatment usually result in a less than complete cure or healing
If you are facing problems getting proper medical treatment from an insurance company, call me or email me today.