Workers’ Comp Case Study 02

Workers' Compensation Case Study | HM&C Law

01
HM&C Law recently finalized a claim that has been active since 2007. The Claimant sustained injuries to her back that required surgery and fusions. During the recovery process, she was given an opioid prescription in order to cope with her pain, which unfortunately led to a dependency.

The Claimant suffered an occupational injury in May of 2007 when she was involved in a motor vehicle accident. She was treated by an orthopedic surgeon from April 2007 through April 2012. Her treatment included two surgical procedures and medication.

Her care was transferred to a pain management specialist whose treatment consisted of managed medication through November 2017. She returned to her orthopedic surgeon for further treatment in 2014. In August of 2015, the orthopedic surgeon opined that the Claimant had developed chronic opioid dependency and that she should be seen by an appropriate specialist to her address opioid dependency and determine whether she was able to work.

In August of 2016, an Appeals Officer issued a Decision and Order reversing the determination of the Third-Party Administrator (TPA) to deny Permanent Total Disability (PTD) to the Claimant. This decision was exclusively based on the assertion that the Claimant’s current opioid intake inhibited her from performing basic functions of life.

It was at this time that HM&C became involved in the matter, Extensive litigation occurred after this Decision and Order, which resulted in an Order Adopting Settlement and Dismissing Appeals issued by the Appeals Officer in November of 2017.

HM&C and the TPA, realizing the potentially fatal danger that the Claimant was facing due to her opioid dependency, worked with opposing counsel to provide the Claimant a transfer of care to an unbiased physician.

In January 2018, HM&C and the TPA successfully helped the Claimant transfer to a new, unbiased pain management specialist to wean her from her medications. In November of 2018, the pain management specialist opined that the Claimant was suffering from post-laminectomy syndrome due to her opioid use and that she was refusing any further de-escalation of her medications. In December of 2018, he clarified his opinion, noting that the Claimant refused to decrease her medications since August of 2018. He released the Claimant to full time employment, with restrictions.

The TPA issued a letter, in December of 2018, informing the Claimant that her PTD benefits would cease on December 31, 2018, as she had been released to work. However, the TPA and HM&C were still concerned about the Claimant’s wellbeing and thus scheduled her for an intake evaluation at the Las Vegas Recovery Center.

Unfortunately, when the Claimant failed to appear for her appointment, the TPA and HMC quickly closed the Claimant claim in order to prevent further abuse of medication, and to adhere to the recommendations of the treating physician.

In January of 2019, HM&C and the TPA scheduled the Claimant an Independent Medical Examination with a Rehabilitation Specialist to ensure that the Claimant was in a healthy state. The specialist opined that the Claimant had reached Maximum Medical Improvement and required no additional treatment other than pain management. He also concluded that the Claimant did not have a PTD and could return to work in her pre-accident position.

Throughout these many different evaluations and determinations, the Claimant had appealed many of the TPA’s determinations closing the Claimant’s claim. However, the Appeals Officer ultimately found the non-treating physician’s report and the arguments of HM&C to be the most convincing.

As a result, we successfully litigated to help our client by preventing ongoing unnecessary care. We also helped the Claimant by providing her with the care necessary to wean her off her dependency. Furthermore, the Appeals Officer agreed with our arguments that the Claimant was not permanently and totally disabled, and affirmed the TPA’s determination to close the claim. Finally, it was found that HM&C and the TPA properly scheduled the Claimant an in-patient detoxification program.

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