Q: Worker's Comp denied surgery twice, now they want to settle. My doctor said don't and get a lawyer. Should I?
I was denied surgery twice although my doctor (the one they suggested) and their QME doctor both said that I needed the surgery. The claims adjuster said that I cannot appeal the surgery until a year later from the last denial date. (which will be in Sept). They want to settle with money and lifetime medical care. I saw my dr today and he said don't settle. Get a lawyer so we can get the surgery done. Should I settle and wait the 3 months to appeal and they may possibly approve my surgery or should I get a lawyer and drag it out?
A: Did "they" (a UR Physician? an adjuster?) deny surgery according to all the rules and regulations??? was the surgery requested in in line with the regulations?? If it was late, did you file to move the surgery request in front of a WCAB Judge to decide?? How much does this surgery cost, retail (if your private insurer won't cover it but you need to work again)??? If you have an infection or a stroke or a deep clot from the surgery, will your insurance cover that and your time off work?? and how much will THAT cost?? I'll bet the adjuster never explained to you that if your physical circumstances change and there is a new condition and the reporting physician re-requests the procedure but in complete compliance with all the regulations and overcoming the UR physician's complaints, so the ur doctor approved it, she's paying for it now. Your state legislature and governor have put in the most insane system not no lay person can get any real treatment without a lawyer, and you are a perfect example. Unless this adjuster is offering you $250,000 to cover all contingencies, get a lawyer ASAP.
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