Workers comp legal question

[richard200593]

Not sure if anyone has advice but it can't hurt to ask. I will try to be as vague as possible without getting into to much detail, if you message me with specific questions I will answer.
I recently tore my meniscus at work, the doctor and my company are both pushing the insurance company for me to get an MRI to determine if physical therapy will heal my tear or if I will need surgery, insurance company says they are still looking into the case and will respond within a week if the MRI is approved. If I understand correctly My company pays the workers comp claim, so if they want an MRI approved with doctors consent it should be approved right?

Also-I am now stuck on "light duty making my hourly wage daily which comes out to less than a quarter of my average check due to normal compensation being on a different scale , is this legal or anyway around this? I thought that's what workers comp was for

[jewel25]

Originally Posted by richard200593

Not sure if anyone has advice but it can't hurt to ask. I will try to be as vague as possible without getting into to much detail, if you message me with specific questions I will answer.
I recently tore my meniscus at work, the doctor and my company are both pushing the insurance company for me to get an MRI to determine if physical therapy will heal my tear or if I will need surgery, insurance company says they are still looking into the case and will respond within a week if the MRI is approved. If I understand correctly My company pays the workers comp claim, so if they want an MRI approved with doctors consent it should be approved right?

Also-I am now stuck on "light duty making my hourly wage daily which comes out to less than a quarter of my average check due to normal compensation being on a different scale , is this legal or anyway around this? I thought that's what workers comp was for

What is the size of your company?


If they are pushing for the MRI to see if it is really a workers comp issue, then they will pay. Even if they decided it is not WC, then they will still pay for the MRI, because they pushed you to get the MRI done to see if it is really a WC. Hope that makes sense.


Don't quote me on this, but it doesn't seem right that they have decreased your paid because you have to be on light duty. Once again don't quote me on this, I do have to dig into that a little more. Also since you are in CA they have different employment laws that the rest of the country.

[CHMSC]

Now we have to get authorization for anything in WC. It typically takes 7-10 days for it to go through UR. They will issue an auth or denial. Really depends on how good of a report your doctor writes and if he is available for a peer to peer if the UR doc wants to speak with your doc.

Also depends if your employer and insurance company are accepting the injury or trying to deny it.

As far as your pay they shouldn't reduce it just because you are on light duty.

[richard200593]

I will get a little more personal for a better understanding of the situation. I work for a moving company of about 500 employees. My pay is based on the weight of the household items and ocassiomally when I do not have a job I can work in our warehouse for a small hourly rate and that is the "light duty" they are limiting me to now

[jewel25]

Originally Posted by CHMSC

Now we have to get authorization for anything in WC. It typically takes 7-10 days for it to go through UR. They will issue an auth or denial. Really depends on how good of a report your doctor writes and if he is available for a peer to peer if the UR doc wants to speak with your doc.

Also depends if your employer and insurance company are accepting the injury or trying to deny it.

As far as your pay they shouldn't reduce it just because you are on light duty.

I was just going to post about the 7-10 or sometimes longer waiting period. Either way the MRI should be covered under Medical (I know people have high deductibles these days) or WC Insurance.

WCI doesn't protect the employee, just pays them out for the cost of their medical bills. What is really does is protects the employee from suing the employer for the cost of medical bills. More than likely you are waiting for the WCI company to approve the claim and say yes, this is workers comp and we will pay.

Originally Posted by richard200593

I will get a little more personal for a better understanding of the situation. I work for a moving company of about 500 employees. My pay is based on the weight of the household items and ocassiomally when I do not have a job I can work in our warehouse for a small hourly rate and that is the "light duty" they are limiting me to now

That makes sense why your pay is reduced. You are working on a commission base salary as long as they are giving you your base salary then what they are doing is legal. This is why people who work in commission base salary system get insurance, such as Aflac to help with the gap.

[jewel25]

It seems from your description that your company is doing everything legal and on point. You are just in the waiting period, which sucks. Hang in there and just follow what your HR staff is telling you. You don't want the WCI to reject the claim because of not following their directions correctly.

[CHMSC]

Originally Posted by richard200593

I will get a little more personal for a better understanding of the situation. I work for a moving company of about 500 employees. My pay is based on the weight of the household items and ocassiomally when I do not have a job I can work in our warehouse for a small hourly rate and that is the "light duty" they are limiting me to now

Then that makes sense. You may want to see if the doctor is willing to take you off work. You may make more on disability than light duty work, granted that's if the ins co accepts the claim but then again you have state disability you could collect as well if your doc is ok with taking you off work. Just giving you some options.


Jewel, private health insurance may or may not cover it. Some will some won't do anything because it's WC. The WC industry has gotten really bad in CA. Everything is a waiting game. Some insurance companies are good about getting the injured care quickly some are very slow.

I have seen people get surgery in a month and have seen some wait five years.

Been in the industry for 14 years and have seen it all.

[jewel25]

Originally Posted by CHMSC

Then that makes sense. You may want to see if the doctor is willing to take you off work. You may make more on disability than light duty work, granted that's if the ins co accepts the claim but then again you have state disability you could collect as well if your doc is ok with taking you off work. Just giving you some options.


Jewel, private health insurance may or may not cover it. Some will some won't do anything because it's WC. The WC industry has gotten really bad in CA. Everything is a waiting game. Some insurance companies are good about getting the injured care quickly some are very slow.

I have seen people get surgery in a month and have seen some wait five years.

Been in the industry for 14 years and have seen it all.

But what if they decide it is not WC and the WCI doesn't pay for the MRI? Does the OP have the cover the cost of the MRI. I would think he would try and have the Private Medical Insurance pay for the cost, since it is something that would have needed to be done if it wasn't a WC claim.

[CHMSC]

Originally Posted by jewel25

But what if they decide it is not WC and the WCI doesn't pay for the MRI? Does the OP have the cover the cost of the MRI. I would think he would try and have the Private Medical Insurance pay for the cost, since it is something that would have needed to be done if it wasn't a WC claim.

If they do an MRI on a lien basis which very few facilities will even do nowadays the only responsible party is the WC ins co.

It is illegal to bill the patient for anything unless they committed WC insurance fraud and lied about the injury.

You may still have to pay for forms to be filled out or for a copy of medical records but anything else the patient is not responsible for.

[jewel25]

So I was right to say that the WC will pay for the MRI even if his claim is denied in the end?

[CHMSC]

Originally Posted by jewel25

So I was right to say that the WC will pay for the MRI even if his claim is denied in the end?

Yes and no, if it's denied they will not authorize the MRI and if a company does it on a lien basis then the facility will not get paid but the patient would not be responsible for the bill either.

[jewel25]

Thanks. I think I just overthought it and confused myself.

Hope it helps the OP.

[jewel25]

Originally Posted by CHMSC

Yes and no, if it's denied they will not authorize the MRI and if a company does it on a lien basis then the facility will not get paid.

What I was asking is, what if WC asks for the MRI to investigate the claim but in the end denies the claim then who pays for the MRI?

[jewel25]

Btw, My background is in recruiting so everything I know on WC is what I have pick up from reading, school, and sitting in on WC meetings.


Thank you for the help.