HELP. Legal ? Regarding Unemployment & Worker's Compensation for My Cousin....

Updated on June 01, 2010
A.J. asks from Redlands, CA
10 answers

I AM absolutely livid and have no idea if I can help her out, but I thought the collective minds of all you mamas might be able to help us out. My cousin lives in Pennsylvania. She is 33 yrs old and was on the job working as an RN when she had a stroke due to a tear in her heart. ..Yes at 33 yrs old...And can you believe after a month of rehabilitation she tried to go back to work, and her empoloyer will not "accomodate her reentry into the workplace". This is obviously because she isn't fully rehabilitated...Okay fine she said screw you I'll find somewhere else to work who will accommodate me...Meanwhile she needs to have the tear fixed on her heart. The cardiologist schedules a procedure he's done dozens of times no problems in the past....And guess what her INSURANCE..denies authorization because they deem it as "experimental". You've got to be kidding. Her doctors have said this is the 1st time ever had it been denied. They've appealed and appealed still denied. Now the Doctors office told her she needs to start contacting all the congressman and legislature she can...LIKE she has the time or energy to do all of this...AND the kicker out of this since she had the stroke while at work...LOGICAL thought process at work= WORKER'S COMPENSATION INSUR. is responsible.... nope they denied all claims saying they're not responsible then her PRIVATE INSURANCE is saying no it happened at work Workman's comp is responsible......And NOW she's being denied for UNEMPLOYMENT...ugg any thoughts?? Someone has to help this poor lady out....She has two kids boy/girl twins 9 yrs old and a loving husband, but with her illness this added stress is just so unjust!!!!

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answers from San Francisco on

Her employer's lack of cooperation to accomodate her limited activity means instead of quitting her job she just should have filed for disability instead. Her company's HR rep not informing her of this when they were "uncooperative" puts them at fault. It's time for legal counsel. Something official on legal letterhead sent to her HR department and corporate headquarters is in order. Maybe she has a friend of a friend who's a JD and can help her in this regard.

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answers from Redding on

So sorry this is happening to your cousin. And, I didn't read the other responses so I aplogoze if I've repeated anything.
I don't know about PA laws, but I'm very familiar with workers' comp and health insurance in CA. (I'm a licensed, but non-working agent).

In my opinion, the first thing your cousin should do is talk to her doctor about getting her on state disability. I realize she tried to go back to work, I'm guessing because they need the money, but let's face it, she had a stroke due to a tear in her heart that needs to be repaired. I broke my right leg doing yardwork and was placed on state disability until I was healed up enough to be able to drive, etc. Her condition is far more serious. Again, I'm not sure about PA, but in CA, disability pays far better than unemployment. That will get some money coming in and help with her stress levels while she is under her doctor's care and she appeals to get her procedure paid for, etc.
Now, as for Worker's Comp, I completely understand why they would deny the claim. At least initially. If she can prove that the tear in her heart occured as the direct result of something she was doing at work, such as lifting a patient that was too heavy or something heavy falling on her, that might be one thing. Something occuring at work and being a work related injury or illness are very different things. So, she's got that to consider.
Now, as far as unemployment, it's my guess that they are denying her because she voluntarily said she would find somewhere else to work. That's voluntarily quitting, which unemployment insurance will deny a claim for. She can argue that she took their not being willing to accomodate her re-entry as being terminated, but the employer may say, "We weren't comfortable with her coming back to work just yet."
The other thing about unemployment is that you cannot be too sick or injured to work or look for work. If the employer tells them she's recovering from a stroke and in their opinion tried coming back to work too soon, DENIED. Which again is why she needs to speak to her doctor about state disability and discuss with her when she may or may not be actually released to return to work. With something as serious as this, it shouldn't be up to her necessarily, she's not been repaired yet.
Hopefully she hasn't burned any bridges with her employer and once she's released to resume normal activities at work, they'll be happy to take her back when she's well enough.
As far as insurance, and I don't know what carrier she has, (some are definitely better than others), she could just be caught up in the "you pay, no.....YOU pay" vicious cycle to the point a third person just said, to heck with it, let's call it too experimental. Personally, I don't see how she will get worker's comp to cover this as upsetting as that may sound so she should focus on getting a case manager assigned to her claims, etc with her private health insurance so everything is with just one person, in one department. If her cardiologist has gotten this procedure approved for someone else through the same insurance carrier, without violating the privacy of the other person, that needs to be pointed out. Having said that, keep in mind that a procedure that's been done dozens of times before, doesn't mean it's covered by an insurance policy. One example is that some policies will cover gastric bypass surgery and others won't. It doesn't necessarily mean it's because it's experimental, it may simply mean there is no provision in the policy for it or it's clearly excluded as not covered. What she needs to get her hands on is an "Evidence of Coverage" booklet if she doesn't already have one, which in essence is the very long drawn out booklet that outlines coverage, your rights and responsibilites under the policy, etc.
As far as the appeals, if you keep approaching things from the same angle, they will keep getting denied from the same angle. I'll give you a couple of examples:
A client, an attorney of all things, was having trouble and getting her medical claims denied. She had an agent helping her, but the agent just kept submitting the bills and time after time they were denied. 10 months later, she brought this huge folder of stuff for me to try to figure out. It took me less than 10 minutes to figure out what no one at another agency OR at the insurance company had noticed. She was a 53 year old woman and someone at the doctor's office had submitted the bills with a diagnosis code for infants. She clearly was not an infant and didn't even have an infant on her policy, so the claims were just denied as a matter of course. All the doctor office had to do was resubmit the claims with the proper code and all her back claims were paid.
A client's little boy was playing with his cousins and got hit in the face with a toy. He had to go to the emergency room not only for his facial injuries, but a pediatric dental specialist was called in due to damage to his teeth and gums. They got him fixed up and the little boy, although pretty seriously hurt, was going to be okay. The insurance carrier took one look at the claims from the dentist and denied them because "there are no dental benefits under the health insurance policy."
Someone sitting in a claims cubicle simply saw claims from a dentist and automatically denied the claims. They clearly didn't look at the procedure or diagnostic codes or they would have known that the claims were for physical trauma to the mouth related to a medical emergency. It took getting the right person to sit down long enough and look at the claims to get them paid. And they WERE paid.
So, just another thing to throw out there if for her doctor to check the procedural and diagnostic codes included in the request for authorization.
Also, check to see if her cardiologist is not a preferred provider for that insurance carrier in which case they can request an "out of network referral".
No offense to her doctor, but contacting congressmen? I'm pretty sure they're on vacation right now.

I'm sorry this is getting long.
I think she needs to take a deep breath. Have her doctor get her on state disability. Forget about unemployment for now. Forget about worker's comp for now. Get a copy of her policy. Find someone that knows about insurance coding. It may be that it needs to be coded in such a way that shows it's follow up for her stroke and not something they just out of the blue decided she needs to have. She knows the name of the procedure, have her look it up to see if it's considered experimental.
All I know is, it sounds like appealing and appealing has garnered the same results so a new approach is necessary and I would start with the insurance carrier. There are ways to get things done.

I really wish her well. Stressing about all this isn't helping her.

Best wishes.

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answers from San Francisco on

My husband is a workers' comp lawyer in California and he doesn't know how things work in PA. But he said your cousin should immediately file a workers' comp claim with the PA WC Board (if she hasn't already), although he said there's a good chance the tear would be considered NOT work-related unless she was doing something pretty physical when it happened (e.g., moving a very heavy patient). He also said your cousin should immediately appeal the denial of unemployment, plus immediately file for state disability if she hasn't already. Also, she should continue to pursue all avenues against her health insurance, including any further appeals that may be available or even arbitration if that's what the health policy provides for, especially if the cardiac surgeon is willing to back her up. Under Calif. law if the workers' comp insurance carrier denies liability for the injury, then health insurance is required to cover the treatment. Then the health insurance carrier can file a lien in the workers' comp case and get reimbursed by the comp carrier if turns out that the injury is deemed work-related. A health insurer's refusal to provide treatment in these circumstances can be "bad faith" unless it has a reasonable basis for the refusal. My husband has serious doubts about the justification of the denial of the procedure as "experimental." She should also contact her state legislators' offices, as well as the state insurance commissioner. Although this takes a lot of time and energy, she needs to do it. A lot of insurance companies win just because people get discouraged and give up.
Good luck!



answers from San Francisco on

Wow, sorry she's going through this. My husband's an attorney and he said she definitely needs to talk to one who knows Pennsylvania law (we're in California) since Worker's Comp is a state law. Employers have to accommodate you if 1) you're determined to have a disability and 2) it's possible. The definition for determining a disability is a legal one- not always what we think as a logical one. You have several different issues here: The job/disability, Insurance and unemployment. When Unemployment is denied, you can appeal it and ask for a hearing. Since all this takes time and energy, she needs to get someone to help her- a relative or friend nearby. Start by calling an attorney or local Legal Aid (for lower income) and keep records- notes, medical, etc. Good luck!!!



answers from San Francisco on

Hello Amy,
Having fought this battle and taking 5 years and several operations( & I am the mother of 5 with a disabled child and a husband with cancer-- that means nothing to any of them) I can say that what they feared is just what she did go back to work to soon and have something go wrong. Since she quit she may not have much luck with unemployment. I was never successful with that either. If she wants to get this taken care of then she will have to take whatever time is needed to do all the foot work. The proof has to be given from her side that this really happened at work due to work related things vs while doing something else ten going to work and making a claim. Get her to make copies of all tests,xrays, and paperwork. She will need all this as it seems to disappear. I had one doctor that had a receptionist loose the films and charts and the doctor was furious.
Your getting mad wo't help her but letter writting can, be informative and to the point it seems that the congress offices we wrote to said the letters were to long. I am surprised that her private insurance won't help and then they go collect from the hospital Worker's Com. really hated it wen I went to mine.
Good Luck


answers from Stockton on

I think that she should contact a local news station in her area and see if they would possibly do a report on her and bring to light what these companies are doing to her. Usually these companies do not like to have their names in the media with a negative story so possibly that would get her some much needed action on their parts....I am so sorry to hear about this situation and wish that I had some magic solution to give you, but that is really the only thing that I can think of. I am not sure what the laws are in Pensylvannia, but would think that if her work was unable to accomodate her since she is not fully rehabilitated that she should still be able to collect CA that would be the case as far as I know, but the laws are different in each state.



answers from Sacramento on

This is definatly not a workers comp issue, her health insurance should cover this, and she needs to not pay out a dime until they do. She will have to get a hold of the appeals department at her insurance company and tell them that they need to pay up. Workes comp issues are things like, falling on a puddle of water at work, or cutting yourself at work. She has a health issue that caused her to have a stroke, that is what her health insurance is for. As for getting the procedure covered, again, she needs to get really nasty with her insurance company and get all the data she can to prove it's not experimental from her doctors. This really sucks that she is going through this. She should also ask her doctors to continue to try to help her get this covered.



answers from Oklahoma City on

I have worked in HR and workers comp and I must agree that workers comp is not responsible. She would have to prove that her job specifically played a roll in causing her to have the stroke for workers comp to be applicable in this instance. Contacting congressmen and legislature is how things do get changed but that of course won't happen overnight that can take years. Has she looked into temporary disability?



answers from San Francisco on

First off, it's not workers comp, at least not by california standards. yes, she had the problem at work, but it wasn't caused by her work. it was just a coincidence that it happened while she was on the clock. Second, if the treatment is not truly experimental, then yes, definitely contact senators, congressmen, and for heaven's sake her local TV stations. insurance companies tend to stand up and pay attention when they get national coverage for denying a claim. But there really isn't a quick fix. Try writing a heartfelt letter to president obama. Remember, his mother died of cancer all the while fighting the insurance companies so you may get some sympathy/assistance there. I understand she can't get unemployment - if she's not fully rehabilitated, she can't look for work or accept work if offered so she's not eligible for unemployment, at least by California standards. It's an extremely tough road she's on and I pray for her and her family. She's going to have to get her insurance company to change their mind and she's going to have to be on disability because unemployment isn't going to work.


answers from Los Angeles on

I used to have to get patients approved for worker's comp. (in cali). Worker's comp will only pay for accidents involving the job, like tripping over something, slipping, etc. Because her stroke happened at work, does not mean workers comp is responsible. They have to have a link that the job cause it basically. Did her private doc submit paperwork to the insurance company stating the reason for the tear/stroke. See if she can have her doc do that. That might clear up confusion as to her priate insurance saying worker's comp is responsible. Would her previous job had kept her position after she was fully rehabilitated? If so and she left because it wasnt happening fast enough, they probably wont approve her for unemployment. If she stayed she might have been eligible for paid family leave through the state, due to illness. How long was she at this job as an RN. If its a big medical facility or a hosp, you know what they hate more then anything. Bad publicity. Call the local newspaper or news chanel. Part of our news has an investigative newsman. He will go to companies waving his mic and trying to get an interview. Some companies actually "right the wrongs" so to speak. My prayers are with your cousin and her family. Good Luck and let us know what happens.

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