Pete was denied his meds by Workers' Comp, and the answers he's getting reminds me of the variable rate housing crisis. It seems his employer paid an insurer for Workmen's Comp. That insurer sends the claims to an insurance adjuster. And the insurance adjuster has turned it over to Third Party, or is it a third party, and they're saying his meds now cost too much.
Of course, chronic pain gets worse, not better. And drugs lose their potency. And new drugs cost more. So, yeah, I guess the costs to them have increased. But like with the adjustable mortgage rates, what else did they expect?
So what will happen to Pete. Will they foreclose on his pain meds? Will the third party get a bail out? They spend a lot of money denying claims. Maybe the Workmen's Comp companies ought to start lobbying for socialized basic meds. There's still lots of room for supplemental insurance.
Damn, I have better things to do with my energy than fuss about this. Like beading.
I decided to combine 2 things I don't like. Some heavy grey nylon thread (heavier than the size 5 I have), and some weird size 6 beads in a sort of amber, violet/peri, olive AB. So they will become another bead crochet bag, along with some amber leaves, green flowers, a few brown leaves I have left, etc. It will be uncharacteristically "organic".
They cant deny payment of medication if they have approved the comp claim and have been paying for the doctor visits, therapy visits, and meds. The TPA is only doing what the adjuster/carrier has told it to do... and thats deny the payments of the medication or just plain deny auth for the meds. The adjuster/carrier has ultimate financial control over the entire claim so what happens to the claim is the adjusters fault.
What kind of doc prescribed the meds? Orthopaedic, pain management, Chiro? Well, most Chiro's are not docs but you know what I mean. hehehe
If it was an Orthopaedic doc who prescribed the meds, then I would insist he get an IME (independent medical evaluation) with a pain management doctor.
Has he had an FCE (functional capacity evaluation) yet? Has he reached MMI (maximum medical improvement) yet? Has he been given a disability rating yet?
Does he had a nurse case manager assigned to the case and does he/she go with him for his doctor visits?
I don't know where you guys live, and each state's comp laws are very different and also differ in how claims process, but if you have not already done so - I would make sure your hubby files a claim with your states work comp commission.
If you want more info on how to fight comp insurance carriers, send me an email: sterling{@}cox.net
We called the insurance adjuster, who told us that the meds were being denied because the costs for them (new ones) were more expensive and the Third Party people didn't count on them being so much. But she did go ahead and authorize the meds. And asked Pete to call her Friday. So Pete now has his meds. At least for this month.
Pete was originally injured in '91. After a bad snow storm he was sent from here in Fairbanks to a place near Anchorage to clear electric line, to a co-operating power company. He was told he could NOT use his own saw and was given an extra heavy old one that had no vibration protection. He worked 35-40 hours straight, and after that could not move his hands. The next week he couldn't work, couldn't lift his arms. The doctor said they could see no damage, but gave him various surgeries. He was off all that summer.
(That winter his son was born, and weeks later his psycho wife left him).
Halfway through the following summer (he worked 7 months a years for 20 years) a job was created for him which was less physical, and paid the allowable 60% of his original rate. He continued to have pain, surgeries, loss of muscle control,etc.
Ten years later, a couple months after I married him, he fell at work and re-injured himself. After trying to work for a week or two, he was no longer able. He filed with Workmen's Comp. He was consistently told he had nothing wrong with him, nothing showed up in X-rays, etc. He changed from the orthopedic surgeon to a general practitioner of better quality, and better listening skills. He was given a settlement of $30,000, and has not been able to work since then. He was finally officially diagnosed with Myofascial Syndrome/ Fibromyalgia several years ago. His related medical costs are supposed to be paid for.
One of the big problems we have is that the forms are so difficult for us. Pete was going through a divorce as well as pain with the first injury and wasn't able to give it the attention it needed. In addition, Pete has a disability that makes reading extremely difficult for him. With the second injury, I was with Pete, but I have limited mental energy because of Depression. (I don't get sad, my brain just gets tires). Brains also get tired due to in people whose brains are bombarded with pain and new unmanageable job and identity loss ("over-stimulation" is my psychologist's description of Depression).
And you know, mentally ill people, people with Depression, which pretty much includes all injured and traumatized people should not have to represent themselves in negotiation with insurance lawyers. And because lawyers can legally only receive 10% (as opposed to their standard 30%) in legal fees when working on WC cases, none of them will take these cases on.
So we both have trouble keeping up the fight. Being constantly vigilant doesn't work well for either of us. Even Kathy NV had trouble with having to constantly re-prove her case, and she did everything right. We're just trying to keep on keeping on.
The claim has been settled, so I don't know if more fighting is possible. Though if they deny his meds maybe the case could be re-opened. At the time of his re-injury it was not possible to sue the employer for injury due to unsafe equipment thanks to new "conservative" pro-business legislation.
I wish we had had better resources to fight for a better settlement at the time. Especially legal resources.
InspirePoint website is not affiliated with any of the manufacturers or service providers discussed here.
All logos and trade names are the property of their respective owners.