My Workers Compensation Nightmare

Xray of bilateral femoral neck (hip) fractures

Have you ever thought about what would happen if you hurt yourself at work? You would file a workers comp claim with your company and get paid while you recovered, right? Well, you would file the claim, but the payment part is anybody’s guess if you reside in the United States. If you are thinking that it can’t happen to you, the truth is, YOU ARE A FOOL Got your attention now? Yeah, I thought so.

The workers compensation system was started as a safety net to protect workers who were injured at work. However, in its current state, the system is a joke at best. The workers compensation insurance industry used to be a big money loser until nationwide reforms in the early 1990s. Since then, workers compensation insurance companies profits have exploded, employer premiums have decreased, and the financial and emotional exploitation of the injured worker has become standard operating procedure. The saddest part is that it isn’t expected to change any time soon!

We all saw the explosion of TV news magazine reports in the early 1990s showing hidden videos of workers saying they were too injured to work, but were caught lifting furniture and moonlighting while drawing big checks for their work-related injuries. Inevitably, the story always ended with a reporter confronting the liar with a tape exposing them as a fraud. As an injured worker, I would LOVE to know where these fakers worked and who their workers comp insurance carriers were because I am here to tell you, it is no picnic! I am not alone and my story is all too common. While shows like 20/20 and Dateline were busy secretly following around the workers, they were missing the employers committing fraud right under their noses. Read this excerpt from a February 2000 Consumer Reports article:

“The Texas Research and Oversight Council on Workers’ Compensation” found that in 1996, fraudulent billing by doctors and other health-care providers cost about $1.2 million–more than eight times the $134,000 in phony worker claims that were uncovered.

In Florida, a 1997 grand jury report found that about 13 percent of a sampling of the state’s businesses carried no workers-comp coverage, even though most are legally required to do so. Florida, Minnesota, Arkansas, and California have started efforts to prosecute employer fraud, but in many states it’s not a priority. Claimant fraud is a felony, but a company’s failure to carry workers-comp insurance may be only a misdemeanor.”

This article did not even touch on the epidemic of employers who would rather fire an employee than report the injury. Why should they do the right thing? There is every incentive not to. The 90s was the decade of the employer – they have enjoyed years and years of ridiculously low premiums while making employees prove beyond a reasonable doubt that they were hurt at work. And unlike the bozos caught by the TV news shows, most workers don’t file false claims, nor do they have the benefit of cameras and videotape to document their injuries. OJ Simpson had an easier case to prove. In fact, if you are injured in this country right now, you better pray that someone is secretly taping you or that your employer has the guts to do the right thing because the odds are you will lose. Further, if your injury does not heal quickly so you can return to work, you stand to   lose your credit rating, self-esteem, possessions, including your cars and home, your family, and maybe even your life. I am not some radical on the fringe of society who believes in government conspiracies – I AM YOU!

The fact is, your employer and its workers comp carrier will work together against you to avoid paying a claim. You want to know the worst part? THE CURRENT SYSTEM ENCOURAGES IT! They even have a name for these tactics – it’s called ” starving out ” the employee. They know that if they can put your claim off long enough, you will either go back to work regardless of whether or not you are healed, or just plain give up. If you stop and give up your claim, the employer will not be sanctioned for their refusal to pay. The insurance company just closes the case and acts like it never happened. Even when the employee does persevere, the employer and insurance company have absolutely nothing to loose by putting off payment. The law supposedly provides ” penalties ” for employers and insurers who starve people out, but the penalties are so low, it should be a crime to even call them penalties! So, the bottom line is, the only thing improved by the reforms is the system’s ability to exploit the injured worker. Think about it – how long could you go without a paycheck? If you live In California, and you are injured badly enough to prevent you from working, and your employer’s insurance company denies your claim, you can receive state disability, provided you qualify. Your employer and their insurance carrier are banking on the fact that most people cannot sustain their lifestyle without a paycheck and will usually return to work prematurely. They make you feel like a criminal when you ask for the benefits that the law is supposed to provide. Any moron that would fake an injury to have the pleasure of receiving benefits is just that: a MORON! I would like to meet the person who is getting rich on this system. I’m a little rusty in my math skills, but from where I sit, I’m having a hard time believing that ANYONE would put themselves into this system ON PURPOSE! In California, the MOST any claimant can receive is approximately $490.00 per week. So, for anyone earning over $32,000.00, the motive of money just isn’t there.

Even if you are finally blessed with benefits, there will be strings attached. Your employer and/or insurance company will make you jump through hoops to continue receiving your benefits. These hoops can include: being forced to go to their doctors, even if they have to put you on a plane you to get you there; having to wait medically dangerous lengths of time for approvals of tests; having your home watched 24/7 and even having a case worker accompany you to the doctor (yes – actually witnessing your exam!). What happens if you refuse any of these things? Bye Bye money. They know that if you need to keep that weekly stipend, you will consent to such indignities.

Of course, if you are denied your benefits, you can appeal, right? Actually, that is correct; you can appeal. But how long does that take? Use me as an example: as I sit here writing this article, it has been 19 months since I injured myself at work. I did EVERYTHING right. I reported the injury to my employer immediately. I went to my family physician and had X-rays done the day of the injury. (I would have gone to the industrial physician provided by my employer, but my employer denied me that right.) Since my injury happened on a Friday, I had to wait until Monday to see my Rheumatologist (I have Lupus). She put me on disability and said I could not work. Both doctors agreed that my injury was work-related. I reported this to my employer immediately and STILL no offer to send me to a company-paid physician. While on disability, and seven days after my injury, my employer terminated me; I hired an attorney. I kept impeccable records. I saw an IME (Independent Medical Examiner) recommended by my attorney. It is important to point out that the work injury caused bilateral hair line fractures on my hips. The visit to my family physician the day of the injury was the first time I had ever been seen by a physician for anything regarding my hip. Even though I have Lupus, it had never affected my hip. NEVER. During the months after to my injury, I saw FIVE different physicians from THREE different specialties: THREE orthopedic surgeons, ONE Rheumatologist and ONE Family Practice. During that time, any existence of pre-existing disease was ruled out including Osteoporosis and Avascular Necrosis, two diseases of the bone that could explain spontaneous fractures. Finally, six months AFTER the injury, but BEFORE ever sending me to their IME, the insurance company’s claims adjuster who has no medical training, DISAGREED WITH THE FINDINGS OF FIVE PHYSICIANS and stated that my injury did not exist; I had a pre-existing condition.

He did not specify what the alleged pre-existing condition was; just that I had one. Workers compensation law allows an insurance claims adjuster with no medical training to override the expert opinion of physicians when determining if a medical condition is work related. I assumed that when making this decision, the claims adjuster SURELY MUST have consulted with a physician, but after researching this, I found that NO PERSON WITH MEDICAL TRAINING reviewed my records before making a medical decision. In any other situation, this would be called practicing medicine without a license. In addition, if you are diagnosed with a chronic health problem, expect to have any subsequent injuries blamed on that chronic illness. That was January 1999. After the denial, the insurance company had me see their doctor. He did not review the X-rays taken the day of and in weeks following the injury. He issued a report stating that I never had an injury. This came as no surprise considering that the insurance company pays his fees and his practice is supported by injured workers referred to him by the insurance company. His role in life is essentially to help the insurance company stick it to the injured worker. Over the next 12 months, I continued to see the IME referred by my attorney. In November 1999, the injury was declared ” permanent and stationary “. I still have pain and permanent nerve damage and I will never regain full use of my hip. My attorney filed appeal papers and finally MORE THAN 1 YEAR later, I received notice of a mandatory settlement conference with the workers compensation appeals board. I showed up, my attorney showed up, but NO insurance company. The insurance company failed to show to three consecutive mandatory settlement conferences. I finally received my settlement conference in November 2000. TWO YEARS AFTER THE INJURY! I met with my attorney before going in to the settlement conference and he showed me a few things: 1. medical records from my Primary Care Doctor from four months before the hip injury when I slipped down my stairs at home. He had written that I complained of mild transient hip pain. I didn’t remember my hip ever hurting, but since it was in black and white, he said the judge could rule with the insurance company’s pre existing condition claim. If that happened, I would walk away with nothing. Or, the maximum allowable under the law for the loss of the use of one hip was $12,000.00. That was the max I could get; Workers Comp has very strict charts they follow. The insurance company was offering me $10,000.00 to walk away and sign away my rights to any subsequent medical care. Since they had never actually treated me for this injury up until the point, I decided to take the settlement and get these people out of my life. I signed the settlement papers on one condition: I would not sign a waiver or confidentiality statement. I wanted the world to KNOW how STATE COMPENSATION INSURANCE FUND treats injured workers. Send them an email…I’m sure they’d LOVE to hear from you!

Even if you win your case after an appeal, chances are the employer will not pay a dime in penalties or be prosecuted if they get caught breaking the law. Did you know that it is a misdemeanor in California for an employer to conceal an injury of an employee? But if an employee files a false claim, it’s a felony. When is the last time you heard of an employer who was prosecuted for breaking workers compensation laws?

The system is not likely to change any time soon. Let’s face it – there aren’t very many employee groups out there going to congress and affecting change, but you can bet your employer is aptly represented by an industry group when it comes time to amend workers compensation law. A case in point is State Fund Insurance, one of California’s Workers Compensation insurers wants a voice in revising California’s Workers Compensation System! Isn’t that a little like letting the fox guard the hen house?

For more information, read the February 2000 Consumer Reports Article. They did an analysis of the system from a consumer’s point of view and judged the system a miserable failure. Instructions for finding the article are below.

A Los Angeles Times article tells the tragic story of John Suarez, a Hollywood Park jockey who finally had too much when he committed suicide over the 1999 holiday season. His body was found some 6-8 weeks after he hung himself in a remote area of Hollywood Park. He had apparently become financially and emotionally ruined after trying to navigate California’s Workers Compensation system. Instructions for finding the LA TIMES article are below.

Do you have a workers compensation horror story? Email it to the Webmaster. Stories will be posted based on relevance and in the order received.

The Consumer Reports article may be accessed by going to the web site and doing a search for ” Workers Compensation “. Registration and subscription may be required in order to view the article.

The LA TIMES article may be accessed by going to the web site and doing a search for the article date and time. The report was in the Tuesday, February 1, 2000 issue of the Home Edition, sports Section, Page D-3. Registration and subscription may be required in order to view the article.

  1. (February, 2000). Workers Comp: Falling Down on the job. . Consumer Reports, [on line] Available: comp 2/00.
  2. (Tuesday, February 1, 2000) Jockey’s Hardship Followed By Tragedy., Home Edition, Section: Sports, Page D-3.[on line]. Available: LA

Author: Tenayshus