Reasons a claim gets denied

[abaga]

What is the name of your state (only U.S. law)? GA

My WC Claim has been paid and then, I went back to work on 1/15, and all of a sudden, as of that date, they are no longer paying. I am seeing the MD they sent me to as well as the PT they sent me to see.

Why can they all of a sudden just stop paying a claim?

EDIT TO ADD: I'm sorry, I was taken back out of work two weeks after returning, however, the benefits were stopped (to my knowledge medical and wages) as of the date I went back (1/15).

 

[cbg]

Because your claim was closed?

 

[NLW]

I'm confused by your question. They are no longer paying lost time benefits, medical benefits, or both?

If you are no longer losing wages because of your injury, you will no longer receive lost time benefits. That doesn't mean that your claim is closed, or that they won't continue paying your medical bills.

If they've stopped everything altogether, more questions need to be asked.

 

[abaga]

Because your claim was closed?

My case has not been closed to my knowledge. I am still seeing the MDs and in the middle of therapy.

 

[abaga]

I'm confused by your question. They are no longer paying lost time benefits, medical benefits, or both?

If you are no longer losing wages because of your injury, you will no longer receive lost time benefits. That doesn't mean that your claim is closed, or that they won't continue paying your medical bills.

If they've stopped everything altogether, more questions need to be asked.

I am still out of work. I went back for a short time, but was taken back out of work. It is my understanding from my employer, the claim has now been denied as of the date I returned back to work the last time. I was taken back out again two weeks after returning to work as my manager would not abide by the restrictions by the MD when she said she would.

 

[ansan12001]

sorry but your statements cant be understood.
Who sent you back to work after inital injury?
Who took you out of work the second time?
-very important details!
-if you were taken out of work by treating physican (the doctor authorized by insurance company to treat injury), then the insurance company and/or the claims adjuster lapsed on the paperwork and you should have probably have received lost wages compensation since being taken out of work the second time around.
-you should be dealing directly with the insurance company (unless you have an attorney), dont let employer be the middle man.

-your claim wont be closed until you sign settlement paperwork.

 

[NLW]

I agree with ansan12001. You need to call your claims adjuster. Your claims adjuster may not even know that you are back out of work.

 

[abaga]

sorry but your statements cant be understood.
Who sent you back to work after inital injury?
Who took you out of work the second time?
-very important details!
-if you were taken out of work by treating physican (the doctor authorized by insurance company to treat injury), then the insurance company and/or the claims adjuster lapsed on the paperwork and you should have probably have received lost wages compensation since being taken out of work the second time around.
-you should be dealing directly with the insurance company (unless you have an attorney), dont let employer be the middle man.

-your claim wont be closed until you sign settlement paperwork.

The Dr. sent me back with restrictions the employer did not follow after stating they would. The Dr. took me back out of work.

My attorney has been talking with the attorney for the opposing side and that atty knows nothing. He said this is an accepted claim, and they should be paying me, however, they are not. They are going to be deposed, but until then, I am without a penny to my name.

 

[ansan12001]

Unfortunetly, your one of the many people who's claim got messed up and now its gonna be up to you to get it back on track, even though its not your fault. In my experience, you get faster results by dealing with adjuster then the attorney, however, the adjuster might not want to talk to you.
To answer your question, a claim would stopped from being paid for miscommuncation resulting from change in circumstances (the usual reason), just make sure you keep all you documents and paystubs, they will come in handy at settlement. If you dont receive benefits soon, (in california) you can apply for state disability benefits, however, they will want the money back if you are able to eventually collect from the insurance company.

 

[abaga]

Unfortunetly, your one of the many people who's claim got messed up and now its gonna be up to you to get it back on track, even though its not your fault. In my experience, you get faster results by dealing with adjuster then the attorney, however, the adjuster might not want to talk to you.
To answer your question, a claim would stopped from being paid for miscommuncation resulting from change in circumstances (the usual reason), just make sure you keep all you documents and paystubs, they will come in handy at settlement. If you dont receive benefits soon, (in california) you can apply for state disability benefits, however, they will want the money back if you are able to eventually collect from the insurance company.

Well, I just received the notice to controvert saying my not being at work is not related to the claim! The Dr. put me out of work because my employer was not abiding by the restrictions! I have the paperwork to show this. The notice to controvert did was sent out ONE MONTH AFTER THE DATE it should have been sent! Aren't they supposed to file in a timely manner? One month is not timely.

I have filed for STD, and I hope that they do approve it. The adjuster is horrible. She YELLED at me for going to the ER when I was hurt even with the paper from the IC stating I was to go there to be checked. She told me in the state of GA it is illegal (yes, her word) to go to the ER. I know this is a bunch of crap on her part. I asked her if there is a claimant who is bleeding, do they have to wait until they can be seen by a panel physician to be taken care of...that is if they live long enough? She told me to watch my tone.

My BP goes up just thinking the adjusters name!

 

[abaga]

Udpate

Well, the reason has finally come out. The adjuster is stating my time out of work is not related to this claim, which is it! I have the notes from the MD stating I have to be out due to restrictions not being met by the employer.

Now, the IC is wanting to settle my case. I do not want to settle and will not settle as my injury is only a few months old and at some point the Surgeon would like to go in and look inside my knee (I can not have an MRI). He feels on top of nerve damage from the injury, he feels I have either a torn mensicus and/or a torn ligament. Further, they are not paying for all of the things that are related to my knee (another MD, medications, etc).

They are probably hoping I will take a small settlement and be done with it. I'm not that stupid!

 

[ansan12001]

you can settle with the stipulation for future treatment on injury, however, your monetary settlement offer likely be less then what it would have been without open medical.

 

[abaga]

you can settle with the stipulation for future treatment on injury, however, your monetary settlement offer likely be less then what it would have been without open medical.

Thank you, Ansan.

I don't feel comfortable settling at this point. I think I have made that quite clear too!

Thank you again for being so helpful!!