Injured on the Job? Why it may be Best to Consult an Attorney Before Contacting an Insurance Case Manager
Injured on the job and suddenly engulfed with a whirlwind of emotions. Along with the obvious—coping with the pain of the injury—your mind is also firing on all cylinders with numerous questions; Will I be out of work for long? How do I file for workers’ compensation benefits? Does this affect my employment? How quickly can I get back to work doing what I love to do?
While your brain is playing “20 Questions,” your instinct is to immediately contact an insurance case manager. Why? Because you learned how. Probably right after you graduated from nursing school. Instilled in you that a case manager is the person you need to contact immediately in order to obtain the medical care you need, the person who will serve as a neutral liaison between all parties involved in the workers’ compensation claim. This includes doctors, the injured worker, the employer and the insurance company. But that isn’t necessarily the case.
In what could eventually become a war between you and the insurance company and your employer, a case manager can hardly be considered Switzerland. Neutrality goes out the window because the case manager definitely has a dog in this fight, and it’s a big, nasty pit bull; The Insurance Company.
A case manager acts as an agent for the insurance company, pure and simple. Their mission is not to help you get better, but to work towards whatever means necessary to help an insurance company that wants to cut off your medical care and benefits. While theoretically they are supposed to work independently of the insurance company, it’s not uncommon for them to provide the insurance company with information about your injury, what medical treatment you are receiving and/or may need to receive. And the insurance company isn’t the only ear they are whispering into.
Case managers have been known to discuss the injured worker’s case with the treating physician, without the injured worker even being present. The goal is to “influence” the doctor for a return-to-work as soon as possible in order to save money for the insurance company. The case managers might even imply to the physician that certain tests aren’t really needed, or that the injured worker is faking their injury in order to receive a higher settlement (“Hey doc, it seems like she is ready to go back to work now, right?” ).
Nothing good can happen when a case manager talks to your doctor outside of your presence, as it is merely a way of trying to pressure your treating doctor to take action that will result in savings to the insurance company, regardless of whether such action is in your best interest. For example, make sure your doctor is aware that your private health information should not be shared with a case manager, as they may use signed medical authorizations to obtain and review your medical records unrelated to your work injury. They will also share your unrelated medical records with the insurance company. The case manager and insurance company will then use any and all information contained in these medical records as an excuse to refuse paying you the workers’ compensation benefits to which you are entitled. And above all, never permit a case manager to be present while you are being examined by your treating doctor.
At this point you probably feel overwhelmed. Like David when he first saw Goliath come walking onto the battlefield. How can you, just one person, already battling the effects of a workplace injury, hope to go toe-to-toe with behemoths like the insurance company and hospital administration? All you want is to get paid, get benefits started, make sure you get the medical care you need, and get some rest so you can recover from your work-related injury. Unfortunately, those are the very things that cost the insurance company money. You feel hopelessly outmanned, outgunned, and you don’t want to get into a prolonged fight. But it doesn’t have to be that way.
What you need is an advocate on your side in these troubling times. An attorney who will not allow bullying by case managers who obviously have an agenda. Having the proper attorney in your corner will assist you in making sure the case manager knows that he or she isn’t allowed to direct treatment or tell you what treatment to have or which doctor to go to. The attorney’s job is to rein in a case manager that is overly aggressive and doing things that are not only not to your benefit, but also hindering your claim.
Without an experienced workers’ compensation attorney watching your back, you may not realize you have the right to refuse a case manager handling their claim. You may not know that the case manager is paid by the workers’ compensation insurance company to save money for the insurance company and that the case manager reports directly to the insurance company. You may not know that you have a right to receive copies of all reports provided by the case manager to medical staff, the hospital and the insurance company. As your advocate, an attorney will set specific ground rules which the case manager must adhere to under penalty of dismal.
Most nurses are self-sufficient and only want to be left alone to do the job they love; helping those who need help. They are loving and caring and will try to avoid conflict whenever possible, particularly with their employer, who they have a sense of loyalty to. But sometimes fate, in the shape of a pulled back or a slippery floor, will intervene. And when that happens, nurses need their own big dog in the fight.
You may think your workers’ compensation case manager, insurance adjuster, and human resources person are looking out for you, but at some point you will realize they aren’t. You are on a raft in the middle of a big ocean and the sharks are circling. They’ll ultimately decide you’ve been injured too long, or they will manipulate your medical care and medical providers in order to get them to release you from care or say your injury is no longer work-related. Don’t let this happen.
The insurance case manager will start the injury process by making you think you are the one in the driver’s seat. But after awhile you will come to the realization that you’re in a car doing 100 miles per hour and you don’t have your hands on the steering wheel. You need to do what it takes to make sure that never happens. Think of an attorney as your designated driver.
Bruce Lipsey is a partner with the law firm of Lipsey & Clifford, with office in Hanover, MA, Randolph, MA, Mansfield, MA and Boston. He received his law degree from Suffolk Law School, with honors in oral advocacy and brief writing. While at Suffolk, Bruce was named a contributing editor to the widely used lawyer’s resource, Proof of Cases in Massachusetts. He is a graduate of Brown University with Honors and former chairman of the MBA committee on Workers’ Compensation. Bruce focuses his practice in the areas of disability law, which includes SSDI and workers’ compensation law. He represents injured and disabled individuals before the Social Security Administration and the Department of Industrial Accidents. For more information visit www.elclaw.com.