Changing mind about WC

Paul in Cannon Beach

One of our employees filed a WC claim last week for carpal tunnel strain. She works in our laundry facility. I sent in the claim to our WC insurance company.

A couple days later the employee comes in and tells me her doctor says that WC will take months and she would be better off putting the operation on her regular medical insurance.

I call our WC insurance company and they tell me once they have received a claim they cannot "ignore" it. However, they said they can deny the claim, the employee will not seek appeal, and then she can carry on with the surgery and bill her medical insurance.

This is a new one to me. Any thoughts?

[email]paulknoch@hotmail.com[/email]

Margaret Morford

Do not play games with WC and do not let the WC carrier off the hook to deal with this claim. It will come back around to bit you in the form of a permanent disability down the road with the employee claiming you talked her into handling her claim that way.

MYTH: Employees always tell the truth in legal proceedings because they are under oath.

TRUTH: Truth is often abandoned for money.

Margaret Morford
theHRedge
615-371-8200
[email]mmorford@mleesmith.com[/email]
[url]http://www.thehredge.net[/url]

Theresa Gegen TX

The injury is either caused by the workplace or its not. The problem the employee may run into is that it is not her choice! The regular insurance probably EXCLUDES workplace injuries. So she could have the workers' comp deny coverage, then the regular insurer deny coverage.

The employee should get her doctor to opine whether the injury is workplace or not. Then file the claim based on the doctor's opinion.

The employee should not play games with the insurance carriers -- if they think that she is involved in some type of gamemanship, they both may deny coverage!!

Good Luck!!

Don D

[font size="1" color="#FF0000"]LAST EDITED ON 08-30-02 AT 12:44PM (CST)[/font][p]Since it is Friday and I'm 'easy' on Friday's, I am going to agree with both Theresa and Margaret at the same time. Wonder why the doctor said "Comp will take months." Doctors would kill to have everybody walking in to the clinic covered by comp. No bad checks, no (or few) slow pays. I hope he's better with a shot needle than he is with his comp vs reg insurance advice. P.S. Since the comp carrier in effect is working for YOUR company, I would consider reporting this scenario in full to her superior at the comp company.

Gillian

A big, fat NO for the reasons stated and you should also be concerned about the ethics of the person who told you that they would play games. Hopefully, this is one person and not the philosophy of the carrier.

NaeNae55

It's possible this doctor had an experience with an insurance carrier who paid claims up front and then got reimbursed later by the work comp carrier. In my other life I saw this type of subrogation fairly often. However, it all depends on the medical carrier/plan document and the problems that the individual might be having with the work comp carrier. The claim should go through the work comp carrier, and only if there are problems AND the medical plan allows it should the claim be filed with regular medical insurance. Anything else is creeping into fraud territory.

jerkyguy

I was reading your post on the forum. I say that it needs to be handled solely through WC. If you go ahead and do what the employee wants at this point you are setting yourself up for a lawsuit. Make sure an EMG has been performed, which clearly shows that there is damage to the nerve. Then make sure that it is a hand specialist who has recomended the injury be treated with surgery. Also, request a second opinion. It doesn't matter how long the process is, the employee filed it under WC, she told the you the employer and the Dr. that it was work related. Now, you are obligated to follow-through. A second opinion might allow the employee to refute her previous claim that it happened it at work, but be careful not to advise her to say this. Simply tell her, "this is an injury that you are claiming happened at work, therefore, we have to follow state WC guidelines to ensure that your claim is handled properly". Also, consider getting the Industrial Comminssion involved.

Paul in Cannon Beach

Boy, I would love to say that I handled this the way all of you suggested but it didn't happen that way. WC insurer denied claim. EE did not appeal but had surgery authorized by regular life insurance company. I did not get involved. EE is recovering from surgery as we speak.

I don't believe any of my actions have been innappropriate. I don't think the employee is trying to defraud anyone. She simply wants the surgery as soon as possible. I think I would have been more comfortable if the ee had continued with the WC claim but I suppose its her right to decide it was not work related.

Uncharted territory for me!

[email]paulknoch@hotmail.com[/email]

Theresa Gegen TX

Well Paul, I'm glad things worked out. But I stand by my initial statement. If the doctor had told the employee -- this isn't work related or this might not be work related, then I would agree that the employee was in good faith and just wanted her treatment.

BUT, according to your report, the doctor said "worker's comp takes too long." In otherwords, everyone thought it was a workplace injury.

I am glad that she got treatment, but I have had a case where the employee played fast and loose like this and the non-occupational insurance carrier refused to pay for the treatment because it was a workplace injury. Quite frankly, if that insurance company got her initial report where she claimed it was a workplace injury, there would be a good chance they challenge it. I am sure it comes as a shock to you, but my experience is that insurance companies challange a lot of claims for a lot less valid reasons than this.

If this situation were to arise again, I would at a minimum require the employee to get her doctor to opine about whether or not the injury is caused by the workplace. With Carpel Tunnel type injuries, it can be hard to determine.

Good Luck!

Paul in Cannon Beach

Theresa,

This was a learning experience. Next time I will be more assertive knowing the potential risks you and others outlined.

Apparently the ee is resting and recovering from surgery.

[email]paulknoch@hotmail.com[/email]