The care is usually recommended by the company’s own chosen doctor. Without consequences or effective penalties, insurers’ UR is out of control. It has real impacts on injured workers.
Frances Stevens Story Follows:
About Me: My name is Frances Stevens. I’m 47 years old, and I live in the San Francisco Bay Area. About My Family: My wife and I have two children, both boys, ages 12 and 14.
My Job and What Happened:I worked as editor, publisher and founder of Curve, a magazine for lesbians. In 1997, I was injured when I fell carrying three boxes of that month’s magazine to be processed for distribution. I tripped over an area rug and fell. I fractured my right foot. I thought I’d be back to work in two months. Instead, I’ve had numerous spinal and orthopedic surgeries and procedures. Now, I live with two fused bones and constant, agonizing pain in my feet. I have incurable, chronic, intense pain triggered by the injury. I can’t sleep at night. I can’t stand or walk without burning pain in my feet. There is no cure for my injuries. I need help getting from my wheelchair to the bed, bathroom, and aid at meal time and to shower. My wife works and is not always at home to help me. I have fallen several times while trying to do these tasks by myself. I have injuries to both shoulders, my lower back and suffer severe depression at being confined to a wheelchair for the rest of my life.
What this has meant to my life: At the time of my injury, I was an elite athlete: a female boxer. I was in the best shape of my life. I was also a leader in the lesbian community, and would travel and speak all over the country promoting the magazine and our message of pride and independence. I loved my job and my life. Now, I live with two fused bones in my foot. I have been found to be 100% permanently and totally disabled. I was awarded future medical care for my work-related injuries.
The care I’ve been denied: I fell at work and ended up 100% permanently and totally disabled. I’m confined to a wheelchair and in constant pain. An anonymous IMR doctor who never examined or treated me, overruled the doctor and cut off my medications and home health care aide. How can this be constitutional?
How Utilization Review (UR) Delays and Denials Affect Me: I suffer from depression because of the loss of my pre-injury life. Moving my manual wheelchair caused injuries to my shoulder. The delays and denials of pain medication, anti-depressants and home health care aid have compounded my depression and pain. That my doctor’s recommended treatment can be overruled by some doctor who’s never seen me is incredibly disheartening. The IMR doctor declared that home health care is not “medical treatment.” For decades, home health care support has been legally considered part of a medical treatment plan. The system is designed to make it so difficult for people like me that we give up, or die. Insurance companies have so many loopholes to avoid paying what they are supposed to.
How Workers’ Comp was supposed to help me: Workers’ Compensation insurance is to provide medical care necessary to cure or relieve the effects of my work injury. It’s incredibly difficult to navigate the workers’ comp system to get the basic treatments I need to survive. If not for my family and friends, I wouldn’t be able to manage, and would certainly be homeless, in constant agony. The insurance company cut off the medications necessary to relieve my pain and combat my severe depression. They denied home health care for 8 hours a day, 4 days a week, care that meets the State’s own medical treatment guidelines.