Workers' Comp and ADR, esp. in California

KL Aguilar · #1 (**permalink**) 12-08-2006, 05:47 PM

I am a Workers' Comp patient who has cervical stenosis and bone spurs from C3/4 thru C6/7. Local WC surgeon is proposing 4-level fusion, Alphaklinik is proposing 2-level ADR.

I am leaning toward ADR and have more or less resigned myself to paying out of pocket by taking out a home equity line of credit. (OUCH!) But now I have been told that if I go outside the WC network for surgery, I will not receive WC pay for any recovery time.

Someone else must have traveled this road before. If so, could you please advise?

mmglobal · #2 (**permalink**) 12-08-2006, 10:07 PM

KL, I don't know about the WC issues, but the recovery time from cervical surgery can be very short.

Mark

dshobbies · #3 (**permalink**) 12-08-2006, 10:39 PM

I too have no personal experience in this area, but from what I've read, fight. Fight like hell for your rights. Get a second opinion for an adr surgeon and fight, fight fight.

Dale

Michelle · #4 (**permalink**) 12-09-2006, 12:54 AM

My biggest advice here is call a lawyer!!!! Laws change from state to state, but my wonderful attorney got my ADR approved while the device was still in clinical trials! (Because the FDA shut down the study while considering full approval, I didn't get it until after approval though.) But IT IS POSSIBLE!! It takes some effort, but I fully believe it's worth it. Some companies are starting to believe that they're better off spending the little extra now, and hope for fewer future problems, and less time off work post-op. Even if you don't hire a lawyer, most will talk to you once for free. Ask them. I don't think WC can deny you Partial Total Disability while recovering from ADR (even if they don't pay surgical costs), so long as your recovery doesn't go beyond what would be reasonable for the fusion. But it varies state to state. Sorry, all my experience is in Colorado. But it is possible to get them to pay for the surgery. Question is can you wait long enough to fight them? Ask your WC primary doc for a referral to a surgeon who does fusion as well as ADR. Once the WC primary gives his consent for you to see that doc, it should be easier. Insist. And call a lawyer. Good luck!!

KL Aguilar · #5 (**permalink**) 12-09-2006, 03:40 AM

Thanks for all the help. I do have a WC attorney; he is the one who told me about the non-pay for recovery time if one goes outside the system. He opened a book and read the passage to me. He feels my best bet is to go to court and push to have surgery by a California ADR surgeon. However, that is time consuming and I don't have a lot of time due to severe cord compression. I was hoping that someone had already gone this route and could share their shortcuts.

Mark mentioned that the recovery time for cervical ADR is fairly short, but from reading the experiences of some cervical patients, I realize that sometimes there are complications. I have a very public job and often stand all day doing presentations in front of a hundred or more people. I can't just stop and take a break. I will not be able to do my job unless I am completely recovered.

dshobbies · #6 (**permalink**) 12-09-2006, 05:11 AM

My first thought is to get another attorney who believes in you... but I may be reading this wrong.

chasswen · #7 (**permalink**) 12-09-2006, 12:45 PM

when i was in in germany for my adr jessica from ca was getting cervical ADR done. we had emailed each other making and getting the best deals on travel etc.. she was back to work part time at 2 weeks pretty impressive if you ask me!! at 4 months she was full time and drug free!!
GO JESSICA
best wishes
chuck
p/s sometimes we have to say screw it and do whats best for us.

Michelle · #8 (**permalink**) 12-09-2006, 05:18 PM

Have you asked your attorney about asking for an emergency hearing on this? In my experience, even hearing the word 'hearing' got WC to jump. My attorney threatened them with this 3 times-I've never once seen the inside of a courtroom. It seems with the spinal cord compression the 'emergency' isn't unreasonable. I'd hate to see you get a surgery you don't prefer just because they're dragging their feet. The only other thing you can do in the meantime is try to get your WC primary to refer you to that Calif ADR doc. At least you can get the proccess started while working on surgery approval. Wish I could be of more help! I feel for anyone struggling with this!! I actually used my short-term disabilty (sick leave) through my work to pay my time off this last surgery since it was easier than getting my case (which is maxed out) to pay it. Is that an option if you do wind up going overseas??? Good luck!!

KL Aguilar · #9 (**permalink**) 12-09-2006, 08:00 PM

Thanks for the good ideas. I will pursue some of them. I didn't mean to imply my attorney wasn't on my side. We discussed all of my options and he would say something like, "The advantage of this option is ___ while the potential disadvantages are ___."

The cervical ADRs aren't even FDA approved yet, so it will be a hard battle to convince WC.

racergaldar · #10 (**permalink**) 08-24-2008, 03:30 AM

Probably a bit too late for this, but for future viewers in California. When I calculated what my WC benefits would be while recovering, it was about $200 less per week than SDI (State Disability Insurance). Since we CA pay state tax, we also pay SDI (deducted from your payroll check). Therefore, if you're not on WC, you are eligible for SDI (see: Employment Development Department).

I'm in HR and handle our leave of absence even for those not on WC, and they receive disability benefits.

If you (if self-employed) or your employer did not pay into the account, then you're up a creek. If you're employer didn't pay it and deduct it from your check, I would report that employer to the authorities (The U.S. Department of Labor Home Page, Secretary of Labor Elaine L. Chao). This is a legal mandate for all CA employers.

Maria · #11 (**permalink**) 08-25-2008, 04:20 AM

Have Future Medical with California WC insurance co. Have only been advised that if I go outside the country to have surgery with a non US non WC authorized surgeon I will lose my future medical benefits completely.

That isn't applicable to your situation but it's my California WC scenario with future med.

nopain · #12 (**permalink**) 08-25-2008, 05:11 AM

Here is a question with probably no good answer.

I've done a ton of computer work in the past 5 years. I am an employer, I pay into the State Workers Compensation Fund.

I understand a "slip and fall" type injury, but how many cases are actually presented as a result of a Desk Job destroying ones spine?

How in the world would one go about proving it?

How would you even start the process?

Maria · #13 (**permalink**) 08-26-2008, 01:10 AM

That's a good question to which I have no answer although I'm wondering if there was a point in time where you started to see a doctor regarding your spinal problems so there was documentation of the beginning of your spine problems and some diagnostic testing ordered and performed ?

It sounds like it might be viewed as "aggravation of existing injury" and difficult (though not impossible) to prove.

If you pay into the State Workers Compensation Fund it seems like you yourself should be eligible for work related benefits just like anyone else.

Then again.. I know nothing when it comes to this, just throwing some ideas out there that you've likely already thought of.

I'd suggest contacting your State Worker's Compensation Board however I've tried that and it was grueling with fairly poor results in terms of information access. Might be different for you though and can't hurt to try if you've not already.