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Thread Title: TD benefits denied, PQME scheduled, now what?
Created On Sunday February 22, 2009 6:02 AM


soloinca
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Sunday February 22, 2009 6:02 AM

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Hello everyone. I am SO happy to find this forum. Trying to navigate the CA WC system solo has been a nightmare!

Yesterday, I received a letter from the CA saying "Although liability for your workers' compensation claim injury has been accepted, I cannot pay you temporary disability benefits because there is no medical evidence to support your disability status and no return to work."

I am currently receiving SDI benefits.

I have PQME scheduled next month because I received a delay letter regarding the TD benefits.

Does this mean that I must repay my SDI benefits received to date if the PQME does not agree?

What documents do I need to send to the PQME before the appointment to justify TD benefits?

Do I send a letter to the PQME? What do I say? How do I ask him to resolve this issue?

Thanks for the assistance!







Edited: Wednesday February 25, 2009 at 4:12 AM by soloinca

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STEVEPSCA@YAHOO.COM
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Sunday February 22, 2009 8:10 AM

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As the CA is disputing the TTD benefits, you should be provided with the opportunity to select the field of the evaluator, and the PQME from the list of 3 names provided by the medical unit.
There are definate time lines here, so don't delay in your selection.

The CA MUST provide you with copies of the medical/non-medical records s/he intends to submit to the PQME 20 days prior to the appt/evaluation.
You can object to the non-medicals if there are any.

The provision of TTD benefits is dependant upon your PTP declaration of disability...and the inability to perform your job due to the injury.

IF the PQME opines you are due TTD, then you should receive a check from the CA for the balance due between your SDI rate, and the TTD rate, IF there is any. The CA/IC will reimburse EDD for the SDI they paid.
Although it could work in reverse...and you be paid all past due TTD, in that event, you would reimburse EDD/SDI for the benefits you received for the overlapping periods.



<< What documents do I need to send to the PQME before the appointment to justify TD benefits? >>


INMO... I'd wait to see what documents the CA provides to you, what they intend on providing the PQME. There is no reason for duplication here, and that way you don't have to provide your documents to the CA/IC unless there are others that are not included.

At the evaluation, take all of your medical records you have from the DOI...all PTP narrative reports etc.
When at the evaluation you/IW is free to discuss ANY issue in your claim. Keep in mind though there is no treating doctor/patient relationship here....just the attempt to resolve the disputed issue.

You can find more information on this process in LC 4062 http://www.leginfo.ca.gov/cgi-bin/displaycode?section=lab&group=04001-05000&file=4060-4068

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rosellavera
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Sunday February 22, 2009 12:21 PM

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Carrier states: "Although liability for your workers' compensation claim injury has been accepted, I cannot pay you temporary disability benefits becausethere is no medical evidence to support our disability status and no return to work"

If you are currently receiving SDI, you have a doctor's opinion that states you are unable to work. Have the doctor who certified you disabled send the insurance carrier a report indicating that you are unable to work. This should provide them with the medical evidence they need to support your disability status.

Rose

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postscript2
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Sunday February 22, 2009 2:51 PM

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Hi Soloinca:

Welcome to the forums! There could be many reasons why your TTD is being delayed...

There is some missing information here. Are you treating with a W/C doctor? Any gaps in medical appointments or reporting by the treating doctor???

Sometimes, they may give you a work restriction and the employer cannot accommodate it. This would render you "temporarily partially disabled," AND entitled to TTD.

Someone is not communicating correctly here. If you are collecting EDD benefits, it's the I/C who will have to pay back the money and will deduct what you have been paid from your total sum TTD due to you. Too many variables here.

If you provide more info, i.e. what the doctor told you directly, perhaps I could help you. But this is a confidential forum, so don't feel obliged to post anything that you are uncomfortable with!

Usually a PQME is used to determine a dispute regarding injury causation and compensability and need for medical care--not TTD status...

EDD calculates benefits differently than does W/C. EDD will go back to your highest earnings in the last 18 months over a 3 month period. W/C takes your total wages and pays 66&2/3% of them. They are not taxable and subject to a minimum/maximum "cap." I certainly hope your C/A had a good reason to delay your TTD! This sometimes happens when 2 or more employers are involved and each one is trying to stick the liability for payment on the other-can get quite messy and frustrating. I don't know if this is your case--I just find it odd that EDD picked up and not your I/C.

As for providing information to the PQME, walk carefully on this one. You cannot show up with information that you have not shared with the I/C, just as the I/C cannot submit information (non-medical) to the PQME. It would be considered "ex-parte" communication, i.e. both parties must be informed of what documents are to be submitted.

Be certain to bring any "real" copies of X-Rays and MRI films to the doctor appointment. It will perhaps save you from being tested again. I've had so many that I could literally "glow" in the dark!

I presume that you are un-represented? As Steve commented-the C/A MUST provide you with your entire medical record and any non-medical documents. Go over these carefully, prior to your appointment. Also take a copy of what the C/A sent you, in case the records didn't reach the PQME (it does happen).

At any rate, welcome again. This forum has many knowledgable folks who have been in the "system" for years and years. I am a C/A with over 20 years in the business. Unfortunately, I'm now injured myself.

P.S.: You should not have to pay back EDD if the I/C continues to deny TTD, IMHO and professional opinion. You have a doctor who is certifying disability, so it should be a "non-issue." Hang in there...

Take care,

LCS

Edited: Sunday February 22, 2009 at 2:56 PM by postscript2

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soloinca
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Sunday February 22, 2009 3:18 PM

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If I fax to IC a copy of the doctor's certificate that was sent to SDI, would that get the IC to overturn the DENIAL letter that I just received related to TD benefits?

I requested the PQME panel because the claim had been delayed, now it is approved. What is going to happen at the PQME appointment now?

Must I snail mail the med/non-med records within 20 days or is it possible to simply fax them the medical/non-medical records?

Thanks again for all the great advice. (and sorry for all the sillly questions)

SoloInCa

Edited: Sunday February 22, 2009 at 3:45 PM by soloinca

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feelin it
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Sunday February 22, 2009 3:59 PM

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I think postscript meant : But this is( not a) confidential forum?
good luck feelin it

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STEVEPSCA@YAHOO.COM
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Sunday February 22, 2009 4:29 PM

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Here is the information on how/what you do for a PQME evaluation...


4062.3. (a) Any party may provide to the qualified medical
evaluator selected from a panel any of the following information:
(1) Records prepared or maintained by the employee's treating
physician or physicians.
(2) Medical and nonmedical records relevant to determination of
the medical issue.
(b) Information that a party proposes to provide to the qualified
medical evaluator selected from a panel shall be served on the
opposing party 20 days before the information is provided to the
evaluator. If the opposing party objects to consideration of
nonmedical records within 10 days thereafter, the records shall not
be provided to the evaluator. Either party may use discovery to
establish the accuracy or authenticity of nonmedical records prior to
the evaluation.
(c) If an agreed medical evaluator is selected, as part of their
agreement on an evaluator, the parties shall agree on what
information is to be provided to the agreed medical evaluator.
(d) In any formal medical evaluation, the agreed or qualified
medical evaluator shall identify the following:
(1) All information received from the parties.
(2) All information reviewed in preparation of the report.
(3) All information relied upon in the formulation of his or her
opinion.
(e) All communications with an agreed medical evaluator or a
qualified medical evaluator selected from a panel before a medical
evaluation shall be in writing and shall be served on the opposing
party 20 days in advance of the evaluation. Any subsequent
communication with the medical evaluator shall be in writing and
shall be served on the opposing party when sent to the medical
evaluator.
(f) Ex parte communication with an agreed medical evaluator or a
qualified medical evaluator selected from a panel is prohibited. If
a party communicates with the agreed medical evaluator or the
qualified medical evaluator in violation of subdivision (e), the
aggrieved party may elect to terminate the medical evaluation and
seek a new evaluation from another qualified medical evaluator to be
selected according to Section 4062.1 or 4062.2, as applicable, or
proceed with the initial evaluation.
(g) The party making the communication prohibited by this section
shall be subject to being charged with contempt before the appeals
board and shall be liable for the costs incurred by the aggrieved
party as a result of the prohibited communication, including the cost
of the medical evaluation, additional discovery costs, and attorney'
s fees for related discovery.
(h) Subdivisions (e) and (f) shall not apply to oral or written
communications by the employee or, if the employee is deceased, the
employee's dependent, in the course of the examination or at the
request of the evaluator in connection with the examination.

(i) Upon completing a determination of the disputed medical issue,
the medical evaluator shall summarize the medical findings on a form
prescribed by the administrative director and shall serve the formal
medical evaluation and the summary form on the employee and the
employer. The medical evaluation shall address all contested medical
issues arising from all injuries reported on one or more claim forms
prior to the date of the employee's initial appointment with the
medical evaluator.
(j) If, after a medical evaluation is prepared, the employer or
the employee subsequently objects to any new medical issue, the
parties, to the extent possible, shall utilize the same medical
evaluator who prepared the previous evaluation to resolve the medical
dispute.
(k) No disputed medical issue specified in subdivision (a) may be
the subject of declaration of readiness to proceed unless there has
first been an evaluation by the treating physician or an agreed or
qualified medical evaluator.http://www.leginfo.ca.gov/cgi-bin/displaycode?section=lab&group=04001-05000&file=4060-4068




<< Must I snail mail the med/non-med records within 20 days or is it possible to simply fax them the medical/non-medical records? >>


Don't fax... you need to send this stuff with a proof of service form, and/or certified, return receipt requested... CYA here...you don't want the CA/DA coming back with the arguement you have not provided the information....

You still are free to provide ANY information, oral or written at the exam...see the rule (h) above.



<< I requested the PQME panel because the claim had been delayed, now it is approved. What is going to happen at the PQME appointment now? >>


What are you disputing now, other than the TTD issue...?
You will need to have the PQME comment/opine specifically on the TTD issues... providing dates you ARE/WERE TTD. It's important so you can determine what dates there may be an overlap in SDI/TTD benefits.

If there are no other disputed medical issues...then that is all the PQME will comment on.
There is no patient/treater relationship with you and the PQME...s/he won't diagnose, or develope a treatment plan...or comment on what treatment you might need for your injury... just the disputed issues should be addressed in the report.

I would be a good idea if you can form a 'working relationship' with this doctor... s/he will be the one you see in the future if there are more disputed issues.
And by that, I mean to not be shy, but direct, honest plain formative answers to the evaluators questions.
Treat this like a deposition.. yes, no, I don't think so... never say "I never...." or "I can't do..."

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postscript2
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Monday February 23, 2009 3:20 PM

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Thanks Feelinit:

I meant to say just that--this is an anonymous forum, but by no means confidential.

Steve, the PQME still has to perform a thorough evaluation in order to conclude if the injuries have rendered the I/W TTD or PTD. PQME will also need to know the reason for the "delay" and have all medicals in order to draw his/her conclusions.

SoloInCA:

No question is stupid or silly, so ask away!!!

Take care,

LCS

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soloinca
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Monday February 23, 2009 3:31 PM

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Again...I greatly appreciate this info.

Is it necessary to send the PQME documents to both the CA and employer?

SoloInCA

Edited: Monday February 23, 2009 at 3:32 PM by soloinca

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STEVEPSCA@YAHOO.COM
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Monday February 23, 2009 3:56 PM

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You don't provide ANYTHING to your employer.
The ER is not entitled to medical records.

Once a claim has been filed with the IC by the ER... the IC, for all intent/purpose becomes the "ER" for the duration of your claim. The CA/IC makes all the decisions on providing/disputing the provision of benefits...the ER basically has no input....BUT... that said, IF you are experiencing difficulty with the CA/IC, and you have a good rapport with your ER, an ER can have significant input in how your claim is handled...as they are the one actually receiving the 'benefit' of the policy they are paying a premium for.



<< Usually a PQME is used to determine a dispute regarding injury causation and compensability and need for medical care--not TTD status...

Steve, the PQME still has to perform a thorough evaluation in order to conclude if the injuries have rendered the I/W TTD or PTD.
>>



The PQME here is going to have to determine the dates the IW is/was TTD, specific...in order to resolve the SDI overlap issues.



<< You cannot show up with information that you have not shared with the I/C... >>



h) Subdivisions (e) and (f) shall not apply to oral or written
communications by the employee or, if the employee is deceased, the
employee's dependent, in the course of the examination or at the
request of the evaluator in connection with the examination.


I suppose we could argue the labor code until after the PQME report issues...
IMHO... I would wait until you receive the medical reports from the CA that they intend to provide to the PQME and after review determine IF you wish to add additional documentation...at which time, you may cc the CA.
There is no point in being reduntant with the evaluator, and cause duplication of record review...and wasting time...which may in turn be billable to the IC.


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