WC question

[Guest guest]

Thank you for so much information .

This lady was driving her own vehicle in Oregon when she skidded on a patch of ice and flipped over. Safeco is her personal PIP Company so I sent the claim with documentation to Safeco. Then WC became involved. I have now received EOB's from WC denying everything except Neuromuscular ucation and Massage Therapy codes. Interestingly they are covering them well. No adjusting codes were covered.

Do I call Safeco and ask if they will honor the claim since WC has said they won't pay any more than they have?

Do I just submit it to them (with the EOB's of course) without calling first?

Is it better to have her see you or another atty before doing anything else?

I so appreciate your input and look forward to connecting again.

Joan Schultze, DC

RE: WC Question

Your situation may be a little more complicated than most combined mva/workers comp car wrecks. If she were driving as an employee/agent of a federal agency, then you'll need to determine whether the car she was driving was government owed, and if so, whether it has an insurance policy on it that provides PIP coverage for an employee driver (it may not). If the car was her own, then she'll have her own PIP coverage. You'll need to know whether the policy was issued for delivery in Oregon or whether it covered a car principally garaged in Washington, as that will determine which PIP laws are applicable. Is the workers comp provided through the federal government? If it was a government vehicle without PIP, and if the patient has her own Oregon PIP policy, and if the particular government vehicle she was driving was not one "regularly provided for her use," then she may have secondary PIP coverage on her own policy which would kick in where the workers comp fails to pay. Whenever you're dealing with a worker injured in an mva during the course and scope of employment, the interplay between the various insurance policies gets complicated and is fact driven. I know I'm not providing much help, it's simply that there appears to be a lot of additional crucial information that needs to be obtained before you'll know who's going to pay and for what. If it's a Washington employer or a Washington personal PIP policy on her own vehicle, then I'd strongly suggest referring to a Washington workers comp/PI attorney. If Oregon, an Oregon attorney could help. Without an attorney, I think you and your client are going to be spending many many hours just spinning your wheels, as none of the insurance companies are likely to provide you any assistance or guidance in navigating all the legal steps and potential traps you will likely face.

Best Regards, G. , Gatti, Gatti, et. al.

From: [mailto: ] On Behalf Of Joan SchultzeSent: Saturday, May 02, 2009 12:52 PM Subject: WC Question

As long as we're talking about WC, I have a question about a patient I'm treating.

Returning patient skidded on ice 1/26/09 and flipped her car landing on it's roof. She came to see me on 1/28, and I sent the claim to her PIP carrier since it was a one car auto accident. Subsequently a request was made from US Dept of Labor Seattle OWCP office for chart notes which were mailed March 11. She works for the census bureau and was on a work assignment when this happened. When the first EOB arrived this week, no payment was made except for 97112 and 97124.

One of the reasons given was that I did not have x-ray demonstration of subluxation taken proximal to the injury. Another was that she had seen an MD at Kaiser who made a DX of Headache only and since I didn't have a DX code of headache nothing was covered. Apparently on her 827 she listed headache, shoulder pain and sore thumb but made no mention of spinal problems. And even then, I am only allowed to treat subluxation of the spine, (demonstrated by x-ray proximal to the injury,)and headache is not spinal related (in their mind anyway).

The Kaiser MD wouldn't refer her to me since I am not a Kaiser panel member....

So, if this is the end of the road for WC, can I now send it to her PIP carrier? Is this the end of the road for WC? What do I do now. She continues to come for care and is not returned to pre injury status.

Joan Schultze, DC

543 third street Suite A-3

Lake Oswego, OR 97034

(503) 636-6186