I closed out a workers’ compensation claim receiving a settlement in 2010. It was re-injured in aggravation at a former employer when a hoist I was working on malfunctioned, and I was given instructions to continue working with it, forcing my left hand up in a forceful pressure cable retract.
My wrist started to hurt, so I reported it, and I was treated through my employer’s insurance. I was given work restriction and told to continue over-the-counter pain relievers. Weeks passed, and it still hurt when I would make certain hand movements.
I requested to be seen again by the doctor. I did not think at the time that it would be serious. I submitted a resignation since I have been planning to resign from the company, but I found out during my two weeks notice that I would be needing surgery.
The doctor who evaluated the left wrist said that the injury was not caused from work and that it was because the first surgery was a failure. I keep telling the doctor that I have never had any problems up until that time when I had the accident with the hoist. To cut the story short, they decided to not pay for my surgery but are willing to do a settlement instead.
My questions now are:
(1) Are they legally not required to pay for a surgery that complicates a former corrective surgery?
(2) Will my previous health insurance cover the surgery if I retain it through the Cobra option?
(3) Will new insurance coverage from my wife’s employer health insurance deny the current needed corrective surgery?
(4) I had premiums paid for short/long term disability insurance extending past surgery diagnosis and employment resignation.
Can I claim short term disability?
I have a new job that inhibits a start date until I am off of any left wrist medical restriction. Any info you can give would be appreciated. Thanks.
Disclaimer: Our response is not formal legal advice and does not create an attorney-client relationship. It is generic legal information based on the very limited information provided. Do not rely upon the information in our response, or anywhere else on this site, when deciding the proper course of a legal matter. Always get a personalized case review from a local attorney.
Let’s take the questions one at a time:
1. Workers’ compensation insurance is required to pay for medical treatment required by a worker who was injured on the job. To be required to pay, the insurance company must have medical proof that treatment is necessary for the worker’s injuries.
In your case, the doctor indicated your injury was not caused by work-related duties. An insurance company will almost always rely on the doctor’s evaluation. It seems they did just that. You do have a right to a second opinion, however. Ask the insurance representative to send you to another doctor.
Hopefully, after evaluating you, the doctor will confirm your left wrist injury is an exacerbation of a previous injury, and that the exacerbation was a result of your current work duties. If the insurance company does not allow you to see another doctor, you can seek an evaluation from your own doctor.
If your own doctor can confirm the exacerbation of your prior work injury was work related, the insurance company may then agree to cover your medical bills.
2. Cobra is basically an extension of your prior work’s health insurance. If you are referring to your private health insurance, then there is no reason Cobra should not cover your medical bills.
3. The only way to know if your wife’s health insurance will cover your corrective surgery is by reading the policy. If you are listed as an insured, and that insured coverage includes corrective surgery, then you should be covered. If though, the insurance company decides the surgery is unnecessary or that it is tantamount to elective surgery, then you may not be covered.
4. You can certainly make a claim for disability insurance. Once again though, to convince the insurance company to cover short term or long term disability will require medical proof. That proof can only come from a qualified physician.
Learn more here: Workers’ Comp & Pre-existing Conditions
The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from a licensed attorney.
We wish you the best with your claim,
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