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  • Work Comp Back Injury & Bariatric Surgery

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    Old 10-20-2005, 10:48 AM   #1
    WCPI
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    Work Comp Back Injury & Bariatric Surgery

    I was injured last November in a fall at work and the insurance company has been pretty decent until recently. I fractured a vertebra and after conservative treatment and two epidural injections was to have a Pars injection but the insurance company denied it and sent me to an IME. When this happened I finally decided I better get an attorney and did so. When I went in for the IME I got the surprise of my life... He was totally in my favor!

    The IME doc - an orthopedic surgeon - actually gave me a worse prognosis than my current physician and has said I shouldn't be working at all and have in no way reached MMI. My doc has me at very low impact employment. The IME doc stated that if the fractures I have don’t heal within 6 months they usually will not ever heal. His recommendation was to have spinal surgery but my weight is too high for any surgeon to work on me. As a result the IME doc stated in his report to the insurance company that I should have bariatric surgery and when I have lost adequate weight to have the spinal surgery. My own doc concurs with this treatment plan but of course the insurance company has flatly denied any surgery. I have gone through months of physical and aqua-therapy, had three epidural injects (none of which helped) and I'm still in constant pain that causes difficulty in everything from sleeping to performing the "facts of life" so to speak.

    My attorney said she will fill a medical claim with the board here in MN but does not have much knowledge of any similar cases involving bariatric surgery in this type of accident. I was heavy before the accident that is true but since I have been injured I can do little or no exercise and have put on additional weight. The IME doctor said at my age (40) I was still relatively young (bless him!) and if I cannot return to work the cost to the insurance company would be quite high for permanent disability. I would think with their own IME doctor supporting this surgery and knowing the cost involved they’d be more inclined to authorize it. I also think their chances of fighting the surgery are weak when their own IME doctor says it needs to be done. If they send me to another IME then that looks like they’re just shopping around for a more favorable opinion - something that claimants aren’t allowed to do!

    Has anyone ever been in a similar situation and if so, was the bariatric surgery approved?

    Thanks,
    WCPI

    Last edited by WCPI; 10-20-2005 at 10:48 AM.

     
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    Old 10-20-2005, 05:39 PM   #2
    Tirzah
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    Re: Work Comp Back Injury & Bariatric Surgery

    WCPI- What vertebra did you fracture?

    I had a truck roll over accident 12/04 and fractured my t9. I am still not working. I have had most of the consertive treatments and I'm still not doing very well. I have not had any surgery yet. I am dealing with wc and if things don't start happening my attorney is going to get impatient with them as am I.

    I don't know anything about bariatric surgery.

    Tirzah

     
    Old 10-22-2005, 06:35 AM   #3
    WCPI
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    Re: Work Comp Back Injury & Bariatric Surgery

    I fractured my L5 and also have some impingement on my sciatic nerves that is causing all kinds of pain and burning.

    When you say "if things don't start happening" what are you referring to? Are you trying to get approval for surgery or something else?

    Best of luck!
    WCPI

    Last edited by WCPI; 10-22-2005 at 06:36 AM.

     
    Old 10-22-2005, 10:36 AM   #4
    Tirzah
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    Re: Work Comp Back Injury & Bariatric Surgery

    Since my fractures are all in my t-spine I think the doctors that wc is sending me to don't know exactly what to do with me. I know there are not very many drs that know how to treat these fractures. The drs I have seen have treated me with all the conservative treatments and they wait to see what happens. Well nothing is happening and I haven't had any improvement for months. I don't know if I need surgery or not but I am trying to get in to see a spine spec. that treats t-spine injuries.
    Tirzah

     
    Old 10-25-2005, 09:32 AM   #5
    CJnorm
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    Re: Work Comp Back Injury & Bariatric Surgery

    yes i have had 4 back surgerys and it was a work comp ,yes it was hard but they had to give in a aprove them and yes i do have a lawyer and i let him take over ,iam still fighting worker comp iam going to court with them this year cause iam 100% dis ,and they did alot of things that was wrong and the courts will get them ,so hang on they will give in

    CJnorm

     
    Old 10-26-2005, 11:59 AM   #6
    TexMac
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    Unhappy Re: Work Comp Back Injury & Bariatric Surgery

    WCPI,

    I'm sorry you are going through this. W/C sucks. I haven't posted in awhile but I have been going through hell myself. I asked for a 2nd opinion 2 weeks ago and still haven't heard back yet. My MRI's have been lost(I had to track them down), doc appt scheduled for when the doc wasn't even there and now my benefits have been terminated(I found out last night). I'm sure you know the drill. I'm so glad to see you have an atty. Apparently I'm gonna have to go that route too(as the folks here advised me too).

    Can I ask how long you have been dealing with this? I don't have any advice but I wanted to let you know you aren't alone.

    Regards,

    Tex

     
    Old 10-27-2005, 03:23 PM   #7
    WCPI
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    Re: Work Comp Back Injury & Bariatric Surgery

    I had my injury in November of 2004. I held out getting an attorney until the insurance company denied a treatment and requested an IME. I know how it goes (I was an investigator for a number of years) so decided it was best to get an attorney. I would suggest you do the same and the sooner the better. It can take a while for things to get into court and make the insurance company reinstate your benefits if ordered.

    I just got an email from my adjuster and she said they are denying any further physical therapy based on the IME results. Those are the same IME results that say they should pay for my bariatric surgery so I can get a spinal fusion, by the way! My attorney is already filing a motion to have the surgery approved as it was recommended by both my doctor and the IME doctor. Their doc only said he didnít think strengthening the muscles around the area of the injury would help because it is a fracture. I

    They seem to pick and choose what recommendations from the IME report they want to follow. Based on past experience with claims adjusters and the law here I'd say it doesn't look good for them (though I'm not holding my breath for approval just yet) because both my doctor and their IME doctor have said I'm screwed. They could send me in for another IME but then that would look bad. If a claimant can't "doctor shop" an insurance company sure can't either!

    Their doctor is an orthopedic surgeon and pretty well known in the area. He has said I am no where near reaching MMI and should not even be trying to find a job right now! My doctor has put me on light duty at 4/hrs a day / 20 hrs/week max. Their IME doc said based on the fractures he thought that wasnít a good idea. He also said without the spinal surgery I would be totally disabled for the remainder of my life! I donít want this nor do I want that rating! It will cause so many problems and I want to get back to work so I can earn a living!

    Best of luck.
    WCPI

     
    Old 10-27-2005, 08:42 PM   #8
    CJnorm
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    Re: Work Comp Back Injury & Bariatric Surgery

    WCPI & TEX

    I have been fighting workers comp for about 4 years now ,they have denied me many times but thank god i got a lawyer cause i would of been screwed big time ,after 4 years and 4 back surgerys we are now going to court.i hope this is over soon this injury and workers comp has messed up my life and head.


    CJ

     
    Old 10-28-2005, 12:16 PM   #9
    TexMac
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    Re: Work Comp Back Injury & Bariatric Surgery

    WCPI and CJ,

    Well I picked up my paycheck yesterday and my benefits were still on there. I went ahead and paid every bill I had whether it was due or not just in case.

    I've been waiting a month for a 2nd opinion. I was told they will try to wait you out hoping you either die, retire, quit or just pain give up. I was also told to tell them if I injure myself further SOMEONE is going to be liable and it ain't ME.

    CJ can I ask how long it took before you got a lawyer and what pushed you to get one?

    WCPI I hope you keep posting more tips. The tape recorder in the pocket(another thread I believe) was great info.

    Tex

     
    Old 10-28-2005, 03:46 PM   #10
    CJnorm
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    Re: Work Comp Back Injury & Bariatric Surgery

    Tex

    when they fired me for my injury is when i got a lawyer ,that was the day before my frist surgery and now 4 years and 4 surgery later now we are going to trial.

    CJ

     
    Old 10-28-2005, 04:32 PM   #11
    TexMac
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    Re: Work Comp Back Injury & Bariatric Surgery

    CJ,

    That's my worst fear losing my job. I can't imagine 4 yrs of this AND losing your job.

    I got my 2nd opinion approved for this Thurs. This is going to sound so cowardly but I'm scared as hell. Scared this doc is gonna do what the 1st one did...spend 5 minutes with me and say my disc protrusion is "nothing".
    Scared this one is isn't gonna help me either. Scared they will release me back to work with no restrictions and I rupture the disc.

    I'm so tired of the pain, the worry, trying to work through it when I can barely move. WHEW...that's felt good to vent.

    Any words of wisdom CJ?

    Tex

     
    Old 10-28-2005, 05:28 PM   #12
    CJnorm
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    Re: Work Comp Back Injury & Bariatric Surgery

    Tex

    i can't tell you not to be scared ,cause i was scared to death,and mad,i had two opinions one from my doctor and from the workers comp doc and both gave me two options surgery surgery because my L3-L4-L5-S1 was rupturned i hate to tell you this the L3 and the L4 WERE rupturned because they made me work for 3 weeks on my injury SO if they do make you work please be careful AND Tex get a lawyer just in case.and you know if you do get fired from your job it is against the law to fire someone because of their injury.so don't quit your job keep it as long as you can.BUT GET A LAWYER !!!!!!!. are you getting opinions from a workers comp doctor ? or your own doctor?

    CJ

     
    Old 10-28-2005, 06:09 PM   #13
    TexMac
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    Re: Work Comp Back Injury & Bariatric Surgery

    CJ,

    Thanks for posting again. It was their doc. Now for my 2nd opinion: they have to approve the doc...so again...their doc. Is it just me or is the cards stacked against us for an honest opinion. This happened in Feb and all the film the docs are looking at are 7 or 8 months old. I've been working on my feet the whole time. Whatever's happening in there is feeling worse and worse.

    Can you tell me alittle about getting a W/C lawyer. Payment etc.?

    Tex

     
    Old 10-29-2005, 05:00 PM   #14
    WCPI
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    Re: Work Comp Back Injury & Bariatric Surgery

    [QUOTE=TexMac]CJ,

    Thanks for posting again. It was their doc. Now for my 2nd opinion: they have to approve the doc...so again...their doc. Is it just me or is the cards stacked against us for an honest opinion. This happened in Feb and all the film the docs are looking at are 7 or 8 months old. I've been working on my feet the whole time. Whatever's happening in there is feeling worse and worse.

    Can you tell me a little about getting a W/C lawyer. Payment etc.?

    Tex[/QUOTE]

    Explain that you have continued working and that you believe there is further injury that will show in new films (x-rays, CAT scans, etc.) and demand them. First and foremost I must agree with CJ - GET AN ATTORNEY NOW!

    Work comp attorneys work on a contingency basis - that means if you don't win they get nothing. That pretty much shows how sure WC attorneys are that there is something there for them! Here in Minnesota they get 25% of the first $4000 and 20% of the next $60,000 not to exceed a fee of $13,000 unless a greater fee is ordered by a work comp judge or the MN Supreme Court. If they don't think you have a case then they won't take you on but I have yet to hear of any claimant who didn't eventually find an attorney to represent them. If the attorney you're considering asks for money up front walk away - they're not being honest with you.

    Having an attorney working for you is well worth the money because first, if they don't win they don't get paid so they fight to win. Secondly, as soon as you retain one the insurance companies can no longer pull some of the stuff they will try to get away with like waiting you out. You no longer have to deal with them and everything goes through your attorney. The down side is you usually have to make sure you're kept in the loop. My attorney sends me copies of all related communications and documents (which they should) and copies me on all email communications as I do her.

    There are some really good WC attorneys out there but I've always been very leery of the ones running the commercials you see on TV. They're usually handling so many cases they don't have the time to give each one the attention they deserve. I think if you're a good enough attorney you don't need to run commercials to get clients. Up here the only ones you see running commercials usually have reputations as ambulance chasers. I'd do a little research, ask around and get recommendations. Don't necessarily go with the firm that has the biggest yellow pages ad or coolest website. And ask questions about their experience and how many WC claims they've handled, what their standing is with the WC judges (if they'll be honest about it) and choose one that way. If you have an attorney you've used in another area of law ask them who they recommend but check them out as well. I have a referral and then found out the attorney had just started in WC law! Remember, these guys are working for you. And if you don't like the one you pick you can always change. You can also call the local bar association and ask if they attorney has had any complaints filed against them.

    There are good attorneys out there and there are good claims adjusters and insurance companies that are fair - it seems there are just not a lot of them! The problem is that there has been so much fraud in work comp and personal injury that many insurance companies will automatically deny a claim unless it's some guy with a 2x4 sticking out of his forehead - then they'll at least try to minimize the injury to get out of paying as much as they can. If you're really injured and your doctor says so and their doctor says no then your attorney fights for you. I think most WC judges know that IME docs are very favorable to who pays their bills and they take that in to account. I also know that when a work comp judge sees IME report after IME report by the same doctor and they're always anti-claimant they take that into account as well.

    You should also remember that pain is subjective. What is bad for one person may not be as bad for another so it's very hard to discredit the pain someone feels from an injury. I have a high tolerance for pain or so says my doctors and dentist so they know when I say it's a debilitating pain they know I'm in serious pain!

    Best of luck and get an attorney!

    WCPI
    PS: Whenever you deal with the insurance company keep a record of it. Keep all emails, letters, etc. including the envelopes. Start a file and keep track of it all as this will help you and the attorney should you retain one. I record all phone conversations with the insurance company and it is legal. I also do not have to tell them I am doing so. Check the two sites below to make sure you are legally able to do so in the state in which you live:

    http://www.callcorder.com/phone-recording-law-america.htm
    http://www.rcfp.org/taping/states.html (State by state laws)

    Last edited by WCPI; 10-29-2005 at 05:00 PM.

     
    Old 10-30-2005, 12:50 PM   #15
    go*big*red
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    Re: Work Comp Back Injury & Bariatric Surgery

    Okay, I have some questions and some comments. Just my take on the whole thing. Let me first say that I have been on w/c before, but was for a wrist injury and they paid everything. My perspective now, though, is from an employer's point of view.

    First of all, in MOST cases, the w/c errs on the side of the injured worker. I'm sorry, but in Colorado anyway, and in ALL the w/c cases as an employer we've been involved with, that has been the case. And, 3 out of 4 major cases we've been involved with, they have all been back related injuries. And, yes, I am a back patient, but not w/c.

    Secondly, I do agree that after a time, it's best to get a lawyer on your side. But, so many times, the injured worker jumps to a lawyer and then their settlement is cut in half because of the atty's fees when if it could/would have been settled w/o an atty, the injured worker would have gotten much more.

    Thirdly, we have HAD to fill injured worker's positions because they were unable to do the job we hired them for and had no reduced positions available. We do try to keep the position open as long as possible, but are a small mom and pop organization and many times are unable to do so. That may have been looked upon as them "loosing" their job because of their injury when in fact, it was filling their position left vacant for too long due to the injury. It's two separate issues with the same outcome - and we were NOT happy to do it but had to stay in business as there were 15 other families counting on us staying in business.

    And, finally, WCPI, if I understand your dilema correctly it is this......the w/c company would approve your back surgery if the weight was not an issue, but because it is an issue, they are dening the surgery. What you are trying to get approved at THIS time to be paid for by w/c is the bariatric surgery so you can eventually get the back surgery approved. How can this be the responsibility of workmen's comp and ultimately your employer? (Who ends up paying for the whole thing anyway - which is a whole nother issue we won't get in to here) Do you have insurance? Why not see about getting the bariatric surgery approved through them and THEN seeing about the back surgery? It is not the responsibility of workmen's comp to see to it that you are physically fit for any surgery. That is not work related which is what workman's comp is.

    I'm sorry - I know I'm not going to win any popularity awards for this one, but that's how I see it. Please don't be offended as that is not the intent of this reply.
    __________________
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    Last edited by go*big*red; 10-30-2005 at 12:53 PM.

     
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