Worker's comp claim?

[secondcor521]

Hi all,

I have been diagnosed with bursitis in my elbow and the orthopedist is recommending surgery.  (Don't look too surprised.)

It's probably/possibly due to my work environment.

I've spoken with the doctor's insurance and the work ergonomics people.  The former says it should be paid at 100% if it is treated via worker's comp; the latter says that there is no "black mark" on my for submitting it if I think it was work-related.  The latter also says there is some board that adjudicates whether it falls under worker's comp or not.

This would be my first worker's comp claim submitted in my life.  I've been at the current company 5.5 years and have a good reputation I think.  Recommended surgery is outpatient and local anesthetic, so figure maybe $2K out of pocket, which I can afford easily enough.

Questions:

1.  What are the drawbacks/advantages of worker's comp?
2.  Is there a "black mark" on me if I submit the claim?  (I know they said there wouldn't be, but...)
3.  Can I still get treated for the injury the way I want to if it does go the worker's comp route?  (For example, if I'm paying for it I think I'll probably just do surgery, but worker's comp might say, "Hey, try some cortisone shots and see if that patches you up enough."  It may be reasonable for them to have a say if they're paying for it.)
4.  If you were in my shoes, what would you do?

Thanks all!

[SaintM]

Is this a common injury in your field?  If you work at a desk and develop bursitis, the company's insurer will be interested in how often you lift weights, play tennis, etc.

[ltt]

Probably/possibly due to work environment, most likely, will not cut it with the insurance company for filing a claim.

What treatments did your ortho suggest before moving straight to surgery?? 

[WhoopWhoop]

1.  What are the drawbacks/advantages of worker's comp?
2.  Is there a "black mark" on me if I submit the claim?  (I know they said there wouldn't be, but...)
3.  Can I still get treated for the injury the way I want to if it does go the worker's comp route?  (For example, if I'm paying for it I think I'll probably just do surgery, but worker's comp might say, "Hey, try some cortisone shots and see if that patches you up enough."  It may be reasonable for them to have a say if they're paying for it.)
4.  If you were in my shoes, what would you do?

There are not supposed to be consequences for filing a workers' comp claim. If there are, get a workers' comp lawyer. People in the industry will treat you like GOLD in order to try to get you not to consult a lawyer. Adding a lawyer to the mix ups the cost to the employer about $50k (from what I heard), because the law says the employer has to pay for YOUR lawyer AND their lawyer. So, if your employer is smart, they'll try to keep the peace. But, realistically, I have no idea if this will leave a black mark or not.

If the doctor is recommending surgery, and they've tried the conservative treatment route, your employer cannot refuse surgery. They might deny authorization for surgery until after you've tried cortisone injections. But, ultimately, if the doctor recommends surgery, and you never improve, you will get the surgery.

This is my knowledge of California workers' comp. I don't know if it works differently elsewhere.

That's all I know. I can't answer all your questions.

Also, they might ask a doctor to confirm that the injury is likely work related.

[MDM]

4.  If you were in my shoes, what would you do?

1) Do whatever a well-regarded orthopedic doctor suggests is most likely to relieve the pain.  If the suggestion includes surgery, get a second opinion.

2) Be ethical about whether this is legitimately worker's comp.  If it is, do not worry about the company "holding it against" you.  As others have mentioned, in the long run it is much less expensive for the company to cover the treatment rather than subject themselves to a lawsuit. 

It is also less expensive for the company - and better for you - to prevent these injuries.  You might expect - and appreciate - some specific recommendations regarding your work practices to prevent recurrence.  Ignoring those, and getting hurt again, will cause a black mark.

[I'm a red panda]

Is this a common injury in your field?  If you work at a desk and develop bursitis, the company's insurer will be interested in how often you lift weights, play tennis, etc.

I think it will be a very very tough claim to prove.  For instance, my bursitis in my elbow has been shown to be related to how I use a mouse at work.  But, I also use a mouse on my computer at home...

I have had to have a number of ergonomic visits because I am very prone to this same injury flaring up.  It IS due to the repetitive nature of my work, but it is also my participation in life outside of work- including working on my computer at home, lifting weights, doing kickboxing type workouts, etc.  So the best thing I have been able to do is learn how to prevent the flare ups.

I think the best you are going to get is the company to provide you with a more ideal set up to prevent it from flaring up again. (And even then, that can be a fight....)

[jba302]

Hi all,

This would be my first worker's comp claim submitted in my life.  I've been at the current company 5.5 years and have a good reputation I think.  Recommended surgery is outpatient and local anesthetic, so figure maybe $2K out of pocket, which I can afford easily enough.

Questions:

1.  What are the drawbacks/advantages of worker's comp?
2.  Is there a "black mark" on me if I submit the claim?  (I know they said there wouldn't be, but...)
3.  Can I still get treated for the injury the way I want to if it does go the worker's comp route?  (For example, if I'm paying for it I think I'll probably just do surgery, but worker's comp might say, "Hey, try some cortisone shots and see if that patches you up enough."  It may be reasonable for them to have a say if they're paying for it.)
4.  If you were in my shoes, what would you do?

Thanks all!

I was a work comp adjuster for about 5 years for several states -
1. Benefits provided by work comp - full medical, lost time, permanency, vocational rehab if you can't return to your prior job, death benefits to spouse (your bursitis should not get this far).
   Drawbacks - Idaho is employer choice of physician. If you disagree with their choice and the insurance company refuses the change, you have to submit to an Independent Medical exam or file a petition (http://www.iic.idaho.gov/forms/ic_claimant_change_of_physician.pdf). You will also have to follow a fairly straight line protocol of conservative on up treatment unless you have medical support indicating that lower level treatments are not medically necessary. If your ortho is really highly respected and the care is cheap, it could go straight to a scope (personally I would approve it if you are healthy otherwise since cortisone shots are kind of bullshit).

2. Almost all insurance companies submit claims data to an aggregation company. So if you file a claim, the next time you file a claim, it is likely that we'll find out about the prior one. This is not a "black mark" exactly, unless you intend to lie about it or are a frequent flier. Termination from employment due to a claim is illegal as well.

3. See the drawbacks. Generally yes, but it really should follow protocol.

4. If your doctor says it's work comp, and his name isn't on the side of a bus shilling work comp care, then you should file a claim. Idaho is fairly conservative on the spectrum but all work comp venues favor the employee.

What the adjuster will do is take a statement from you, your employer, and your doctor. They will go through your medical records to see if you are telling the md if you hurt yourself at work or if you fell off a ladder at home. If everything is legit and your adjuster isn't an asshole the process is very simple. Feel free to let me know if you have any other questions, it can be a real pain in the ass if your adjuster is tough to deal with.

[Jacana]

If you are not sure about the source of the problem, it could be difficult. But as long as you are always honest with them, it is really up to them to decide if you qualify so you can always start the process. If nothing else, perhaps they can assist you and your employer in adjusting your workspace, or finding physical therapy or something.

As for question 3, no. You don't really get to decide your treatment path. Here's my experience from Maryland:

I went through worker's comp for surgery on my hand about 4 years ago for a bad ganglion cyst. WC is a pain.

Positives: I got treated by a top specialist and it was all 100% paid for. I got partial paychecks. Employers and bosses were very nice about it all. I couldn't get fired for needing so much time off or needing some reasonable accommodation when I returned to work.

Some negative things I encountered:
1. Lengthy phone conversations with reps from WC asking me lots of questions about my previous jobs, outside activities, anything at all they could find to pass off the claim, sometimes borderline belligerent or accusative. Remember what you tell them, they write it all down and may ask again later to try to catch you up. But once my claim was accepted everyone was professional and helpful.
2. Whatever the Dr said pretty much was my only option. He said treatment A, I got treatment A. It didn't work, he suggested surgery, I had surgery. His recommendation was law. And I went to whoever they told me to, Dr and PT, no choice for me.
3. Declining a recommended treatment or putting off a treatment in a wait and see approach was not allowed. Either they treated it then or I had no claim.
4. WC and Dr completely controlled when I was permitted to return to work. No light duty, or part time. Either I was on disability and not able to work, or I was fine and didn't need treatments. Period. No matter what I said or wanted.
5. I was on partial pay disability for 8+ weeks until the Dr and physical therapist cleared me for work. They also took all my vacation time before payments kicked in.

All in all, I had an injury, it got fixed, life went on. I also had a very active physically demanding job though that needed 2 steady hands so perhaps with a desk job there would be more leniency about the above issues. But it can be a hassle.

[WhoopWhoop]

Is this a common injury in your field?  If you work at a desk and develop bursitis, the company's insurer will be interested in how often you lift weights, play tennis, etc.

I think it will be a very very tough claim to prove.  For instance, my bursitis in my elbow has been shown to be related to how I use a mouse at work.  But, I also use a mouse on my computer at home...

The claims I've seen for stuff like this (like carpal tunnel) they always accept the case as being a result of repetitive strain at work. Just because you use the computer at home too doesn't mean they can deny your claim.

[secondcor521]

@SaintMichael, I don't really know.  I'm the only one I know of who has had this, but both doctors (@work GP and ortho) said it can be caused by chronic trauma.  I do work at a desk; I don't lift weights, and I only play tennis a few times a year.

@ltt, the GP referred me to an ortho, the ortho said I could do drainage and cortisone shots if I wanted but in his experience that really just delayed the inevitable surgery.  He also said I could just try to live with it, but that everyone eventually comes back and asks for the surgery.  He also said that cortisone shots / drainages had a 5% incidence of infection.

@WhoopWhoop, thanks...my company has offices in CA and around the world, so I'm not sure whose rules they follow.  Could be CA, could be ID.

@MDM, there's already a 2 inch egg-foam pad on my chair's armrest! (I put it there)  Believe me, it's not really worth the pain to get "free" surgery.  If I do get the surgery, it's like 1 day off from work for the day of, but then doc says and I plan to work the next day and through the recovery period.  I have a desk job anyway, the heaviest thing I lift is a pen.

@iowajes, yeah, I don't really know.  I switched into a manager job about 3 months ago and the only thing I can figure is that I started leaning on my elbow more because I'm in phone meetings a lot.  The pain started about 6 weeks ago, so the timing fits.  But I am not really sure either.

@jba302, thanks.  That's what I sort of thought about the conservative treatment first.  I am healthy otherwise.  This would be my first claim in my life after working for about 25 years, and since I'm FI/OMY I am nearly certain it will be my only one.

A couple of other things...

It doesn't really seem like it would cost my employer that much more, since they'd be paying for most of it via the regular insurance vs paying for all of it via worker's comp.  As I alluded to above, I don't really think I need anything more than that (I don't need time off, or accommodations, or change of job or anything like that.)

I did talk with both the GP and the ortho.  In both cases, we discussed the possibility of it being a work thing, and I said I wasn't sure.  In both cases I did fill out paperwork and checked the "No" box as to if it was work-related, because I wasn't sure and didn't want to be a bother.  But the ortho said that in his opinion it was a chronic (like an ergonomic) type if injury since I know I didn't bump it against a wall or fall or anything.  I don't know how much that might be an issue.

Honestly, I would like to take the approach that I'll talk to my work about it and see what they think.  If they don't think it is, then I'm fine with it.  If they think it is, I'm fine with that too.  I'm willing to let them have some input on treatment if they're paying and it seems reasonable.  If they want to go with five cortisone shots over one year or want to hire an intern orthopedist to do the surgery, then I'll say, "Thanks, even though it was work related I'll go my own way on this one."

[secondcor521]

@Jacana, I took a brief look this afternoon at all the forms I would have to fill out and all the rigamarole makes me just want to say that I'll take care of it myself.  I'm curious how restrictive/prescriptive Idaho and my employer would be.  I don't think I would have any trouble with the adjusters; I'd just tell them the truth and let them do their jobs.  Although the accusatory tone would probably offend me.

Thanks to everyone who replied, I appreciate it!

[Cressida]

I'm a little late on this, but: I used to work for a workers' comp insurer. One thing I would try to find out is whether your employer is self-insured.

Your employer has two options. One is to purchase a workers' comp policy through an independent insurer. If they do this, it's because they want to eliminate uncertainty in exchange for paying a predictable yearly premium. In this situation, your claim is against your employer's insurer, not against your employer. Your employer is unlikely to care much whether you submit a claim unless it's severe enough to get their premiums raised or their policy canceled outright (if the insurer determines that your employer maintains a dangerous workplace).

The second option is to self-insure. In this case, the employer is gambling that anything they might have to pay out in claims will be less than the premiums they would pay to an independent insurer. Here, the employer is directly on the hook for your claim. Most employers do purchase stop-loss coverage to cover their asses in the case of a REALLY large claim, but it probably won't kick in unless you lost an arm or something.

That's just for your information. If it were me, I'd probably think twice in the second case. But it's true that it would be illegal for your employer to hold it against you.

[Rocketman]

The other point is your company probably pays for the medical expense one way or another.
With WC they pay the claim or if outside insured, their experience factor rises a bit and they "pay" the claim over the next five years with a slightly higher premium.
With Regular Health Insurance they end up paying the claim (less your deductible, etc) through health insurance expense.

They will likely be more concerned with making your area better ergonomically, if it is process through Workers Comp.

Good Luck with the recovery.

[jba302]

I did talk with both the GP and the ortho.  In both cases, we discussed the possibility of it being a work thing, and I said I wasn't sure.  In both cases I did fill out paperwork and checked the "No" box as to if it was work-related, because I wasn't sure and didn't want to be a bother.  But the ortho said that in his opinion it was a chronic (like an ergonomic) type if injury since I know I didn't bump it against a wall or fall or anything.  I don't know how much that might be an issue.

Honestly, I would like to take the approach that I'll talk to my work about it and see what they think.  If they don't think it is, then I'm fine with it.  If they think it is, I'm fine with that too.  I'm willing to let them have some input on treatment if they're paying and it seems reasonable.  If they want to go with five cortisone shots over one year or want to hire an intern orthopedist to do the surgery, then I'll say, "Thanks, even though it was work related I'll go my own way on this one."

This might be a problem, and will depend on what the doctor notes say otherwise. I have won claims based on that little check box.

Jacana - What state are you in? Taking vacation away for a work comp claim is illegal unless your current employer is not the one that you filed the claim against. The only thing that should be running while collecting disability payments is your FMLA clock. Your points 4 and 5 make me think your HR screwed you by making you take half vacation days and half WC. If an employer is unable to accommodate light duty, full benefits are required by law.

[Jacana]

Secondcor521: Maryland. But the main office was in Ohio I think? I dunno. I wouldn't be surprised if they weren't allowed to make me use my vacation, there were some other crappy things they did to employees. I ran into the same problem with maternity, I could no longer safely do my job but they wouldn't transfer me to a safer position or give me light duty, my options were use my vacation up then go to long term disability, or quit. So I quit.

Apparently that was legal because that's what they do to everyone with any kind of disability, suck it up or go out on disability. So I would have needed a dr to sign off on my pregnancy 'disability.' I knew a few other pregnant coworkers who suffered from this BS too. I was actually told by the idiot HR lady "Well, I worked through to the 9th month, its not so hard" but she frickin worked at a desk next to a bathroom. Ridiculous. I quit and never looked back, my husband said screw it we don't need the money, fuck them.

They were just a shitty company that avoided paying overtime on weekends by giving you a few hours off during a weekday, screwed over people with medical concerns, and generally sucked with raises and benefits. I liked my coworkers and immediate supervisor and boss, but beyond that the company was a bastard.

[Jacana]

Oh I just remembered why I lost my vacation days! So supposedly short-term disability only kicked in after a certain number of days absent, like 5 or something, so until then I either had to use vacation or if I ran out of vacation it was leave without pay. If you had vacaction, time it was automatically applied before LWOP kicked in, not an option the employee could choose. So I lost all my vacation days.

[jba302]

Since people are going to read this thread, this is an important point to bring up-

When you go out on an accepted work comp claim, you should NEVER be charged any sort of vacation, STD, or LTD timer run OTHER than FMLA if two conditions exist:
1. Your doctor has taken you off of work
2. Your doctor has put you on light duty that your employer cannot accommodate.
3. Your claim is from a different employer than your current one.

Every state has a "waiting period deductible" of a certain number of days before you can collect lost time from work comp. If you exceed a certain number of days, this money will be paid to you. In Maryland, it's a 3 day wait / 14 day retro. This means you don't get paid for a 0-3 day lost time, you get paid T-3 for a 4-13 day lost time claim, and you get paid T for 14+ days of lost time. In this case, you should have been retroactively paid your lost time from the insurance company.

If there is ever a fight from HR about this, call a lawyer immediately. Not a work comp lawyer (yet...), someone that specializes in retaliatory HR issues. At some point you'll likely end up getting fired too, since that department is clearly a whole bag of dicks, so document everything that you do with them from that point on.

[Blonde Lawyer]

Not my area of law so this is just life experience advice.  My only concern is that if there is a big chance your work is going to deny the claim, your health insurance company could try to deny it too since you said it was work related.  Realistically, one of the two has to pay but they can take years pointing the finger back and forth.  In the meantime your doctor wants to get paid and if you don't pay it yourself the bills can end up in collections.

[jba302]

Not my area of law so this is just life experience advice.  My only concern is that if there is a big chance your work is going to deny the claim, your health insurance company could try to deny it too since you said it was work related.  Realistically, one of the two has to pay but they can take years pointing the finger back and forth.  In the meantime your doctor wants to get paid and if you don't pay it yourself the bills can end up in collections.

The fastest way to fix this is to fax the denial letter from Company A to Company B and give the denial letter to the billing department of the health care provider. You are right this does happen from time to time (way more than it should) but having the actual denial in hand does amazing things.

Sorry I'm responding a lot here. Rarely does my old job knowledge come into use hah.