Sunday, June 3, 2018

CAN INSURANCE COMPANIES DISREGARD ADMINISTRATIVE LAW JUDGES' (ALJ's) ORDERS?


When can insurance companies ignore judge's orders? Anytime they want to it appears. Following is a case example (this piece is a follow-up and revision of the original article posted last week. It is based on newly received information including a recent ALJ decision).

Let's start with the Notice of Hearing dated 12/9/13.  At the bottom of the document is the signature of a Workers' Compensation Administrative Law Judge. The document says "Defendants agree to authorize Botox injection." The decision is made based on a doctor's report dated 8/2/13. The document also states that the issue at hand is a "Dispute Resolved by Agreement." 

Now, four and one-half years later, the patient states that the injection has still not been done.  

The Proof of Service shows that Minutes of Hearing were served on the interested parties on 12 December 2013. In this post we're not naming the parties or even the insurance company since to the best of our knowledge it is not uncommon for insurance companies to ignore judicial orders. 

The patient was injured in a five-car motor vehicle accident in 1993. The injured party was rear-ended twice and received hospital care. She tried to return to modified work. When her production didn't match pre-injury standards she was fired. Treatment and hospitalization were originally accepted by the insurer. Injured body parts were adjudicated and seemingly were determined to include the lower back, neck, knees, and shoulder. Our documentation reflects diagnoses of cervical disc disorder with myelopathy with severe disc protrusion at C6-7 with progressive degenerative changes superimposed at the injury site. The clinical note at the time said that patient "needs cervical spine decompression because of increasing spinal cord compression and ... is one fall away ... away from quadraplegia (sic)." Despite the gravity of her condition the neck surgery was repeatedly delayed. It was finally done in August of 2017. 

With reference to the lower back patient had lumbar laminectomy at L5-S1, lumbar epidurals, and a caudal block. Patient's left knee sustained meniscal tear. She had three surgeries for right knee meniscal tear. She sustained derangement of the left shoulder. 

Her treating physician or PTP recommended botox injection. This treatment was litigated and eventually supported by the ALJ whose order dated 12/9/13 seems to have been ignored by the insurance company. How is such a scenario possible? Can insurance companies decide which judicial orders they'll follow and which they won't?  

Addendum 7 June 2018

The latest ALJ order is from May 1st, 2018.  It names a specific physician as " authorized to continue to serve as PTP." The victim (formerly, we said "the patient") said that it took over a year for the insurance company to pay her bill and that "due to their mishandling of billing and payments he (the physician) will not be moving forward with me as a patient." The applicant who now lives out of state said that none of the doctors she's talked to are willing to accept California Workman's Comp Cases. It appears that the legally designated PTP has stepped aside. The patient-applicant is now in the proverbial cold. 

This turn of events, coupled with the facts that the ALJ decision of 12/9/13 said that "defendants agree to authorize Botox injection" and that this injection has still not been done after nearly 5 years shows us how some patients get hung out to dry. 

WCAB should assume jurisdiction, perhaps via the equivalent of en banc jurisdiction, and see to it that this patient gets the care that has been authorized by two judicial decisions, the first for botox injection, the more recent for future medical care. 

10 comments:

  1. The situation may be as bad as it seems from your description, but it's unlikely. The injured worker may not understand what occurred at the recent hearing, or she may simply not like the outcome and be telling her version. Insurance companies get away with some unconscionable conduct, but not usually if a competent applicant's attorney is involved.

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    1. How do we account for the fact that in this case the ALJ issued an order in 2013 that the parties ignored? I have in hand copy of the actual order signed by the judge in 2013 -- robert weinmann, md, editor, www.politicsofhealthcare.com

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    2. It's not about my story it's about facts and truth. It just so happens to be my story. I have lived it 26 years.

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    3. L3 L4 L5 S1 Fusion and now after waiting and constant denials for 3 years Im now getting hip surgery threw my own medical insurance because i have waited to long and Im tired of excuses and lies.

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  2. Not as bad as it seems.....It's been since 1993 and you get bet Im aware of everything. The fact is the Insurance Companies are not listening to the Judges and yes I have had multiple Judges that favored for me and Insurance Company went the other way. Also stalling my healthcare and working in bad faith is unacceptable.

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  3. Applicant states she is now getting hip surgery through her own private insurance. If it can be shown that the applicant's claim should have been taken care of through her industrial insurance in the first place, she and the private insurance company can still seek recovery through industrial coverage to repay the private insurer. Applicant and private insurer can combine forces to make sure that future medical coverage is industrial, not private.

    -- robert L. weinmann, MD, editor,
    The Weinmann Report (www.politicsofhealthcare.com)

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    1. Thank you I can barely walk so I NEED this surgery stat. Comp does not care even knowing its there responsibility.

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  4. Class Action or Malpractice should be the next thing that happens. Rules are rules if I have to follow them so should all Insurance Companies.

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  5. Judges need to see this ... Insurance companies are getting away with murder...

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