Workers’ compensation insurance is quite literally hurting many of the patients it was designed to heal. It is a business first and foremost, with purse strings that are guarded well beyond what is required to defend against fraud. The cost of this way of doing business is often borne by those who are already suffering: people who are injured at work, people who are very often in great pain and in need of urgent medical care.
A 58-year old firefighter-paramedic (who asked that his real name not be used) was injured on the job while charging up a hill carrying a 65-lb ladder. His spinal injury caused him to walk with a sharp bend to one side, and he could not keep up with his wife in simply shopping for groceries. Workers’ compensation insurance sent him to a family practice physician who, without even having done a full exam, and despite his persistent pain, told him that there was “nothing wrong” with him. The patient believed that as a public servant, he would receive the best of care; he was surprised to find that, as he put it: “the doctor’s role, quite simply, was to dispose of me.”
Workers’ compensation has become a game of attrition. Like monkeys being shaken from a tree, only the very tenacious can hold on, secure the legal counsel they require, and finally — often after enduring debilitating pain for several months — receive the treatment they need to live their lives with less pain.
The insurance company’s defense in the firefighter’s case was quite simply that it was “subject to interpretation.” This patient fought for 23 months to have the surgery he needed approved. Even now, after the countless legal actions he’s had to take to secure the surgery, the insurance company is refusing to cover the pain medications prescribed by his doctor, relenting only after his attorney appeals each decision.
There are laws in place that protect the patient, but workers’ compensation insurers flagrantly ignore those laws. It is in the interest of its shareholders to do so, and because of backlogs in the system in place to protect patients, there’s little threat of punishment for the insurers. For example, the firefighter who was injured had to file for a hearing after workers’ compensation ignored his request for a new doctor. By law, workers’ compensation insurance has five days to respond, but the patient waited five weeks before finally filing for a hearing. Immediately after the hearing was filed, the authorization for a new doctor came through. If he had given them a grace period of five months or five years, the patient believes it would have taken that long. They simply do not respond to requests for the needed treatments without the threat of legal action. They turn a blind eye because they can.
This firefighter- paramedic who “used to feel bulletproof,” who believed that his employer would get him quickly back to health, said the experience seeking help from workers’ compensation insurance “tried me right down to my soul.”
Oscar Martinez is another example; only 28 years old, he walks with a cane and can’t sit comfortably in a chair. At work for a roofing company, he was pinned between two vehicles while taking tools out of the back of his truck. Several parts of his spine were crushed and otherwise compromised, yet he had to take his workers’ compensation insurer to court three times before his surgery would be approved. He waited in great pain for this surgery, enduring it for a year and nine months. Where is the justice in this? What greater good is served from this intense human suffering?
As Mr. Martinez explained, “The utilization review process doesn’t work. It feels like an automatic rejection on account of costs. But when they are made to see the situation as it is – and they only pay attention when they’re in court – then they see that it’s wrong to turn you away.” If you take the broader perspective, one could say that it works well for some (the insurance company shareholders) and not so well for others (the patients they’re designed to protect).
Each of these men has endured through a struggle that need not be so difficult, and they are not alone. If more patients come forward, we can gain strength in numbers to bring attention to this egregious disservice and work to correct it. Please email Paula@WoundedWorker.org to share your story. Thank you.