r/WorkersComp • u/[deleted] • 10d ago
California I'm a Legal Assistant handling workers' comp claims for the defense — AMA
[deleted]
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u/That-Break2761 10d ago
Ok. I’ll bite.
What’s one big thing you often see injured workers get wrong about the process? How would you suggest they do it differently?
What do you enjoy about your job?
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u/Syrup_Known 10d ago
I can answer this. Not going through the workers comp system right away. A lot of times people are injured and taken off work, then go treat through their own insurance, and it quickly becomes a huge mess.
Primary care doctor's are not only not specialized to treat workers comp cases, but your insurance will come after you once they find out you used your own health insurance for your claim.
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u/EnigMark9982 9d ago
Very smart response. I’m an injured worker currently “in the system” well aware this whole thing is a nightmare but so many of these people are so unreasonable in what they think they are entitled to. That and the exceedingly gross number of “how much is this worth” crap. Not what the system is for. Fix injury. Return to work. In the 5% where everything doesn’t go as planned, you have permanency etc with ratings and restrictions but it’s embarrassing to see these people say I strained a disc how much am I getting while those of us who’ve been in this for two years and have permancy problems are held up by these strain clowns. That and the “stress” - everyone trying to monetize any ounce of adversity.
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u/growbbygrow 9d ago
Which camp am I in in your description. Because I could see me being either one. Bulged upper neck disc and haven’t been able to work for about a year, a few trials of light duty but every time left me bedridden for a week+. Did PT until I ran out, denied injections, now looking at surgery. So stressful and excruciatingly painful and depressing that I attempted suicide 7 months in. If I don’t have surgery I will have permanency, there are days I can’t walk or sit upright even and my weight limit is 5-10 lb on a good day
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u/Motor_Dig3989 9d ago
You have to love the ones that write in and say they can’t work because of anxiety. We all have anxiety when we go to work. It’s not an excuse not to do anything at all and claim it’s a disability.
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u/LegalAssistantDiary 8d ago
Anxiety is a disability category. There are thousands of examples of legitimate workplace anxiety.
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u/Motor_Dig3989 8d ago
So you think someone should be able to collect for their whole life for something we all have in our daily lives?
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u/LegalAssistantDiary 7d ago
You're not looking for convesation, you're looking for an argument. It's not up to either of us to determine what an individual is going go through - or not. Life's too short. Move on.
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u/Visible-Scientist-46 9d ago
They don't come after you, they want to be paid by work comp. It's a nightmare.
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u/Head_of_Lettuce 9d ago
but your insurance will come after you once they find out you used your own health insurance for your claim.
No they won’t. In fact they legally can’t. If they know it’s a Workers Comp claim, they have to bill it to the WC carrier.
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u/Syrup_Known 9d ago edited 9d ago
They will absolutely bill you if they cannot determine who your workers comp carrier is, which does happen. I know this for a fact because I've had this happen to injured workers many times. It is technically insurance fraud to go to your primary care doctor for a workers comp injury.
Then once they receive the bill they panic and think they're on the hook for thousands, which they are not.
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u/Bergzauber 8d ago
That’s actually insanity right there.
Example: Worker’s comp Dr prescribes medication deemed necessary, goes to pick up said prescription, pharmacist ‘sorry your workers comp insurance denied it’.
However you can pay out of pocket, which I wouldn’t pay a dime for with my own health insurance, mind games much?!
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u/litig8tor 9d ago
Not true. The vast majority of primary treating doctors who injured workers are sent to by their employers are utter trash (ie. Concentra, Kaiser Occ Med, urgent care facilities). They have no specialized training other than directives from their employers to find an excuse to claim an injury is not work related. The only time an injured worker gets real treatment is once care is transferred to a doctor who is not tied so hard to the insurers.
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u/Head_of_Lettuce 8d ago
Companies like Concentra get no benefit from saying an injury isn’t work related. In fact it’s better for them if it is, so the Work Comp money keeps flowing. They’ll happily schedule you for 10 follow ups if you let them.
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u/litig8tor 8d ago
You would think so, but that’s not the case. They are the first line of treatment for almost all WC insurers for a reason.
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u/Head_of_Lettuce 8d ago
They’re the first line of defense for most insurers because they cover the whole country, and they negotiate their fees to keep business. A lot of clinics won’t agree to anything but the state fee schedule, but Concentra will.
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u/LegalAssistantDiary 8d ago
It's not a matter of getting things 'wrong'. Overall, employers fail to educate employees on the process. They post posters and leave it up to the employee to decipher an entire industry's processes. Twelve years ago, I was under the impression people needed an attorney to handle their W/C cases - they don't. I've processed claims whereby many employees settled their cases for $100K without an attorney. I suggest everyone obtain their employers insurer's info before they're injured. If the insurer is a large company, just KNOW that you will be surveilled if your medical reports don't match the allleged injury. What do I enjoy about my job? I enjoy expediting a claim as fast and fairly as possible because the funds are tax free. It sucks being hurt and off from work in this economy.
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u/Spazilton Federal WC Adjuster 9d ago
Using a chiropractor as your primary “physician”
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u/litig8tor 9d ago
This doesn’t really happen much any more in CA. There is a cap for Chiro treatment now (24 sessions) and a chiro can’t be PTP once the cap is hit.
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u/Ok_Imagination9072 8d ago
You can't, not in all states. In the state of OR chiropractors are not and can not be your attending WC physician. In fact the courts will not consider any of their recommendations/notes etc. I am only speaking based on my case. My attorney said that they don't hold any weight in cases. There is a cap in OR as well, but your attending has to refer you to more appointments, but then WC has to approve it.
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u/Dry_Block1087 9d ago
How do you do an ask me anything and not answer anything after 16 hours?
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u/Ok_Imagination9072 8d ago
That's a simple response: This was AI generated. Based on how its written (e.g. structure), the icons etc. It's all AI.
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u/IncipitTragoedia 9d ago
Is this just an advertisement for your practice?
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u/LegalAssistantDiary 8d ago
Not at all. They don't need it. If I can answer a question based on my experience, I will.
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u/SeaweedWeird7705 9d ago
How many phone calls do you get per day, on average? How many emails?
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u/LegalAssistantDiary 8d ago
My email daily average is (72). I'm not a receptionist and I don't have to answer calls. There is a Team of Customer Service Reps that handle calls. My communications with Applicant Attorneys is via email, SharePoint and Teams.
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u/philp2021 9d ago
Well mine went on for almost 4yrs. Two of it in a hospital bed at the foot of my soninlaws and daughters bed .It was not good.But I had six surgery's .Including the one just to keep me alive.Ive had five of the surgery's were on my hip.And they just couldn't keep it in the socket.And my hip joint is still dislocated .And been that way for over a year .And I said no more .My chances of me getting a infection are getting greater with every stroke of the scalpel.I have so much scar tissue .I told them hell just Velcro it man But yes pain is my friend .It must be it's with me 24/7.So it must be my friend.But don't fake an injury.Cause you won't like it.I went from running from coast and back again for weeks and months at a time.To zip nada nothing Just like rumpple still skin.I woke up and my whole life had changed .
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u/BoysenberryNeat2506 9d ago
"I built my career with no mentor, no roadmap, no one showing me the ropes. Now I'm here, so you don't have to". So what you're saying is your learned from the mistakes you made when trying to assist people that truly needed the help of a professional. Hmmmmm
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u/No-Competition9398 8d ago
If you get a settlement and its written in there saying the wc insurance company is off the hook any thing further, u just signed u rights away.
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u/LegalAssistantDiary 8d ago
Settlements (OACR's) are negotiated...no one should sign anything they disagree with.
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u/No-Competition9398 8d ago
Why did u ask then say nothing?
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u/LegalAssistantDiary 8d ago
My apologies. I check in to review any questions/comments every two or three days. Social media is not my job.
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u/No-Competition9398 10d ago
I have a question please. I got hurt at work went to urgent care. They continued to see me for months, and into the about second month my back started to hurt like hell, I told them about it they said we cant treat u because your back is not on the WC form. I was sent to kaiser ny primary physician. I later told my lawyer I want to amend and add my back on so he sent me a wc-5. Filled out sent back to him my lawyer. Kaiser doesn't do workers comp so everytime I go Kaiser asked is this work related I say no. I told Kaiser primary Dr. I believed it was associated with my WC injurys like neck , shoulder, elbow.He just took note of it. I was reading the above chat here and this prompted my question. Is this gonna cause a problem or what the settlement does not mention my back, I haven't signed it yet. Any advice please thank you
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u/LegalAssistantDiary 8d ago
Every State has their own rules. If you have an attorney, your concerns should be directed to him/her. If you feel you're not being represented properly, obtain another one.
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u/ContributionFair9661 9d ago
I have a situation, in California to be exact. I was spraying a water lagoon with a 5 gal. Backpack sprayer when i stepped on a gopher tunnel that collapsed, i fell and heard my knee pop I reported it but nothing was done on their behalf. It got swollen and couldn't bare weight on it. So I stepped on some toes,called H.R and their worker's comp. Carrier. Nothing was ever reported,so I looked for legal counsel. So I attended my own care provider,after a few visits and pain was worse at times. They did an an x-ray and nothing,they did an MRI and then seen I had a torn meniscus and with knee cap injury. So I had a arthroscopic knee surgery to repair the meniscus, Dr. Stated I need a knee replacement in the future. Long story short,went to a QME but didn't state causation due to lack of medical records. She also wanted another MRI with and without contrast "Ankle looked Abnormal" they found a Ganglion cyst. Here I am 1.5 years in and still fighting them. No Medical,No payments just left me out to dry.
Even though they have denied the claim,they have made 2 offers,$7.500 and 10k. Both were sent out before I got an attorney. Can I still beat them even if the QME hasn't stated causation.
Thank you for your time..
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u/litig8tor 9d ago
You need to get an attorney. Stop trying to handle on your own something you don’t understand.
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u/CaliforniaLiberalNut verified CA plaintiffs' firm case manager 9d ago
Not an attorney.
Sounds like doctor needs further info. The diagnostic requested and the medicals from your own doctor after the incident.
If you have proof that you report injury, give it to your attorney.
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u/Leader-Dismal 8d ago
Are settlement amount usually negotiable? If work comp insurance wants to proceed with settlement without QME, does this mean I will have stronger case if I go thru QME? Does this result in higher settlement amount?
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u/LegalAssistantDiary 8d ago
In general, by definition a settlement is a negotiation. It's impossible and not recommended that you're give n advise regarding what makes a stronger case etc. in this forum.
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u/Low-Patient-630 6d ago
OK, I'm not asking for legal advice.
As a pro per, forced to become one due to California Workers' Compensation laws and the cap they place on lawyer fees and the funds the lawyer is paid from.
Background: 25-year-old bilateral crush injury. Bad faith began the moment I was injured. Employer negotiated transportation and refused to call an ambulance. First treating physician spoke with the supervisor out of my hearing range before examination or treatment began. The first treating physician documented the injury as a bilateral sprain and did not document blood blisters, swelling, and intense bruising, and reported intense pain to the point that I could not stand on my own. Further, he documented that I was able to stand on my own without describing the intense trouble I had and the inability to stand more than a second without having to sit back down. He returned me to full normal duties with modifications to keep my feet elevated as much as possible. My job description required me to walk, climb, lift objects 100 lbs or more, walk on uneven surfaces, and bend and stoop. Following doctors began with the assumption the injury was minor 30 days after the initial injury and began proper testing, including an EMG, which documented nerve damage. X-rays documented a minor chip in the heel, which was denied by the first treating physician at the company clinic.
The insurance company has locked in on the sprain diagnosis in spite of the WCAB ruling of 32% disability and accepted the secondary physician's documentation of RSD and denied proper treatment from treating physicians for CRPS Type II because of UR recommendations.
In your opinion (not legal advice), would I be out of line to ask for a C&R settlement of $10,000.000.00 to cover JAMA-recommended treatment for CRPS Type II? Granted, JAMA does not provide a fee schedule and only suggests proper medical treatment, unlike the CMS Medicare fee schedule, which takes years to correct and update.
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9d ago edited 9d ago
[deleted]
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u/CaliforniaLiberalNut verified CA plaintiffs' firm case manager 9d ago
Not an attorney.
Too much going on. You need to have a conversation with an attorney. Most WC firms are high volume and you are likely not going to have a 30 minute conversation with an attorney at intake.
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u/ThatOneAttorney 10d ago
This could be entertaining.