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Bureaucratic Bungling

Workers' Compensation Insurance Is Designed To Fail

By James Donahue

Everyone in the United States who works for wages is required by law to buy workers' compensation insurance. This insurance, paid by employers, is regarded as part of the payment the worker receives for work performed.

Workers' Compensation Insurance was created to cover injuries received on the job, or treatment of some medical conditions that are considered to be job related.

Like all government mandated programs, Workers' Compensation Insurance is a bureaucratic nightmare that fails to achieve what it was intended to do. My wife, Doris, and I learned from personal experience that rather than help, the program can actually prevent an injured worker from getting the medical treatment he or she needs to make a full recovery. It generates a financial trap that threatens not only the health of the victim, but the welfare of both the victim and his or her family.

Doris, who has worked for years in hospital laboratories all over the United States, sustained a back injury on October 27, 2001, when she lifted a box containing a sixty-pound bottle of liquid material needed for maintenance on a computerized testing machine she was working on.

She said the pain was so severe it knocked her to the floor. After it subsided, Doris checked into the hospital emergency room where she was seen by a physician's assistant, rather than a doctor. This man sent her home for bed rest, and told her to return the next day if she was still in pain. She was.

What Doris did not know when she reported her injury that night was that one of the papers she apparently signed was a notice of claim for Workman's Compensation Insurance through the Michigan Hospital Association.

That hospital might have received payment, but a lot of doctors and hospitals that got involved in her case after that did not. As we forged through the volume of paperwork and red tape required for dealing with Workers' Compensation claims we discovered that the program can become a nightmare. Most people, unaware of the complex system of rules and regulations involved, are bound to miss some of the hoops the first time through. We discovered that Workman's Compensation is notorious for not paying medical bills and for shutting off claims for help if a single piece of paperwork is not in place, or a certain "T" is not properly crossed. If a doctor's secretary, or hospital insurance claims worker makes a mistake the bill becomes the patient's responsibility.

We discovered that doctors are so leery about the way the Workers' Compensation system works, they often turn away job injury patients rather than deal with the program. I suspect that those who do agree to take on these cases usually only give minimal care, avoiding spending any time with the patient, diagnosing the problem, or bothering to even treat the injury. They run claimants through with maximum speed, sending them off to programs that generally work for the largest number of cases and (if they have a conscience) may cross their fingers and hope the patient gets better.

They do this because they usually don't get payment for their services, and I suspect that even if they are paid, the amount is far less than they get from fees to other patients. Also I am sure that Workers' Compensation involves, even for the doctor's office, lots of extra paperwork and there are multiple billings before a single penny is paid.

Thus it was that we became caught in a web of red tape that became so complex in my wife's case, we spent months just trying to reach a diagnosis of what happened to her.Of the seven doctors and three physicians' assistants who were first involved in her case, none of them seen to agree on a diagnosis.

An attempt to by-pass the program and use our own medical insurance company to seek treatment failed. That is because our insurance company learned that it was a job related accident and referred the claim back to worker's compensation. And because we selected a doctor without approval from the worker's compensation consultant, the claim also was denied by worker's compensation. It was a classic "Catch-22."

We got through this dilemma by using the following formula:

--Persistence in fighting, clawing and screaming every step of the way. Buying, begging and finagling every scrap of paper dealing with the case. And there was lots of letter writing to the Workers' Compensation office, the hospital where the accident occurred, and even to the local newspaper.

--Hiring a lawyer (outside of the area without local political ties or personal friendships with doctors and hospital administrators) who specializes in workers' compensation cases.

--Spending hours of research on the Internet in case histories and reports concerning back injuries. Every report obtained produced new "technical" medical words, in typical medical jargon. Every report thus required a new round of research until we deciphered the coded message and learned what the writer was really saying.

--Once determining what was known about my wife's case, we pressed the doctors to go farther to order more tests to either rule out or confirm (our) suspected diagnosis. This is the hardest part, because doctors sometimes become angry when patients enter their office knowing too much about their medical history, and directing the doctor in what to do next. I think it has something to do with ego. We must all remember that the doctor isn't the patient. He is the guy who has the power to order the tests, the treatment and the medicine. Even though we know what we need, the law does not allow us to do it ourselves.

It took us months to fight our battles. In the meantime, Doris' condition worsened to the point where she was losing control of her body. It turned out that the culprit was not an on-the-job accident, but an attack of a treatable nerve disorder that was not job related. What began as an "injury" could have been treated with proper diagnosis and care. In fact, our own medical insurance should have accepted her case.

My concern about worker's compensation programs is that they are designed to wear down the average person who might be too incapacitated and too weak to fight. Like the Income Tax, the paperwork and the complex moves required to successfully endure a Worker's Compensation case are enough to confuse the most intelligent victims.

This is just one more argument in favor of socialized medicine. If we were living in a socialist country, or had a workable medical program operating in the United States, Doris would have been quickly back on her feet, back on the job and living a normal, productive life. Now that she is receiving proper treatment, Doris is living an active life, but in the process of battling workman's compensation, she chose to retire early and for a while accept Social Security disability. And I should tell you . . . that was another hassle.