Worker's Comp Dispute

We have an employee who had a back injury in 2002. His doctor recommended an MRI, and based on the MRI findings, he asked for a discogram. The insurance carrier that is handling the case (not our current carrier) has continued to refute the need for discography. The carrier has referred the employee to two doctors it works with in this area. The first one didn't have a copy of the MRI (and didn't want to see it), and the second one looked at the MRI, said he saw something a little out of whack, and recommended back stretches and anacin. Neither of them would discuss the problem described in the MRI (some kind of a tear and disc leakage). In the meantime, the employee is on restricted duty and has constant pain in his back and on down into his leg. The individual handling his case at the insurance company told him he was just getting old and a discogram probably wouldn't prove anything. Do any of you have a suggestion for getting the insurance carrier to listen to reason and allow the employee to get the exam he needs without going through the dispute resolution process? The insurance carrier has given an impairment rating and considers the case closed. We're in Texas.


  • 3 Comments sorted by Votes Date Added
  • Have the employee work through the worker's comp system. The Worker's comp commission will assign an ombudsman to help the employee. But the time frames for appeal are short and strictly construed!!

    At this point, your opinion will not matter to the carrier because they have no ongoing relationship with your company. And you do not want to get in the business of managing these things.
  • You say your employee has been issued an impairment rating. If that is so, that only occurs after a medical provider dedcides that the employee has reached MMI (maximum medical improvement). It appears that your carrier is correct and that your employee isn't entitled to any other treatment if he is at MMI.It's over and your employee can return to work perhaps under ADA!!! Your employee may have a permanent disability which would be covered under ADA and perhaps needs a "reasonable accommodation.???
  • That's what the dispute is about. The doctor who requested discography feels that the employee can possibly be very much improved or totally recover with proper treatment. However, a discogram is the ONLY way he can determine if treatment will help, and if so, what kind he needs to provide. Without further medical attention, most likely the employee will remain disabled. EE doesn't want to accept that if there is a medical application that can prevent it. He feels the workers' comp system is unilaterally subjecting him to long term disability by rejecting his doctor's request. EE is also very critical of the care he received from the doctors to whom he was referred.
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