Q: WCI is refusing to pay for the surgery that the doctor they sent my husband to has recommended. What are our options?
My husband tore his right maniscus on the job 12/5/18. WCI has been very slow processing his claims. It took 3+ weeks to get an MRI to find the tear. We went to the doctor that WCI said we had to go. The dr stated that he needed surgery to repair the damage. Yesterday, 1/16/19, WCI stated that they were going to send him for physical therapy and not surgery. The dr that WCI sent us stated today that therapy will cause more damage, and that surgery is a must for proper healing. What rights do we have here, and what should we do now? This is taking too long, and all the while my husband has been required to continue coming into work and just sit at a desk. He is usually working out in the field as a service tech. Also, his employer was aware before all this happened that he was considering early retirement when he turns 62 in about 6 months.
A: Short answer, you need an attorney and I think you probably know that. Your attorney needs to let the adjuster know what the authorized treating physician ordered: surgery. If they want a second opinion, fine, but sending him to PT has not been ordered and could make him worse. If an attorney can't take care of this for you by talking with the adjuster, an attorney/you will have to file for a hearing immediately. There are many issues here and speaking to an attorney regarding this matter will not cost you. The early retirement is irrelevant. I wish you and your husband well.
A: Your husband needs an experienced workers' compensation lawyer to force the insurance company to do what they are supposed to do. If the authorized physician recommends surgery, the insurance company has to provide the surgery. If they refuse, a lawyer would request a hearing to have a workers' compensation commissioner order the insurance company to do what the doctor says needs to be done. The insurance company could try getting a second opinion and then if your husband disagreed with the second opinion, a hearing could be requested for a commissioner to decide which doctor to go with. Sometimes they order a third opinion "tie breaker", depending on who each of the doctors are who have already given opinions. What the insurance company can not do is simply disregard the opinion of the authorized treating physician and dictate treatment all on their own without a doctor's approval. It is especially troubling that the authorized doctor says physical therapy will make things worse - the insurance company really has no business trying to have him do PT and I think a commissioner would agree. Unfortunately, the slow authorization is not all that unusual or out of line and neither is making your husband come in and sit at a desk (unless he's written out of work completely), but to blatantly disregard the authorized physician and attempt to dictate the treatment is not acceptable. Your husband need a lawyer.
A: Sorry to hear about your husband's injury. What you are describing is not uncommon. The insurance adjuster disregards the medical professional's advice because surgery is more expensive than physical therapy. If your husband has surgery, then he will be written out of work while he recovers from surgery and the insurance company will have to pay him for lost time. If he goes to physical therapy the adjuster can keep making him go to work (sit at a desk) and doesn't have to pay any lost time. If your husband tries to refuse physical therapy, the adjuster will claim he is refusing care and stop paying anything. If he goes to physical therapy his knee is damaged more. The only way to address this is by hiring an attorney. An attorney can refuse physical therapy on your husband's behalf because of the need for surgery. A deposition of the doctor will confirm physical therapy will damage your husband's knee more. Your attorney can request a hearing to address the adjusters unreasonable behavior. At age 61, your husband has Social Security and Medicare issues to take into consideration. It's also possible that your husband will have an Age Discrimination Act (ADA) claim if his employer is deliberately trying to get rid of him. There are several excellent Workers Compensation lawyers in the Rock Hill area. You and your husband should meet with one as soon as possible. I hope he makes a swift recovery.
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