Are we getting screwed?

Hi,
My husband, a PE teacher, injured his knee in April playing basketball with some of his students. Then, because he was immobile and possibly due to a bad knee brace he wore to work for a while, he got a deep vein blood clot in his calf below the injured knee. In the first weeks after that we went to the ER several times and he had two ultrsounds of the calf, both confirming the presence of the blood clot.

Schools Insurance Authority agreed that it was a worker's comp case, so we are required to go through Kaiser for everything, but when we went to the ER we went to our local hospital (Marshall) which is not Kaiser. I make this distinction because the issue we're dealing with now is that today Jeff went to get a new ultrasound at Kaiser, and they refused to ultrasound below his knee. They said it's not procedure, since they consider the thigh to be the "danger zone" for embollisms. So they did the ultrasound of his leg right down to his knee, but not his calf. And the ultrasound came back negative. No surprise there. The clot was always in the calf (in two veins there).
His occupational health doctor at Kaiser says this is okay because somehow they can determine from the thigh ultrasound whether there's a clot further down. He also ordered a blood test (I forget what it's called specifically) and says that should confirm whether or not there's still a clot.

We've been waiting all this time for the clot to clear up so he can FINALLY have an MRI since the orthopedic surgeon refuses to give him one until he's off his meds for the clot. The logic there is that there's no point giving him an MRI while Jeff's on the blood thinners since the surgeon can't operate, and he'd just have to do another MRI before a surgery later on anyway. So Jeff has had this extremely long recovery from his knee injury, both due to the direct consequences of having the blood clot (for instance, his physical therapist won't do a lot of stuff with him for fear of causing an embollism) and the indirect consequences (the thinners making surgery impossible). So it's nice to hear that the clot is gone, it really is. It just sounds EXTREMELY SUSPECT when they haven't actually looked at the affected veins. It's awfully convenient for Kaiser to send a report of the ultrasound coming back negative to School Insurance Authority, who are then going to figure the clot is gone and doesn't need any more treatment, no more money out of their pockets for that.

So my questions are:
1) Is it really normal procedure to only ultrasound the upper leg?
2) Can doing that truly diagnose the presence or absence of a clot in the lower leg?
3) Will this blood test (it's called a D-tap or something like that) actually reliably diagnose the presence or absence of a clot?
4) Are we on our way to getting screwed here? Will SIA close his case, only for us to find out there is still a problem later because Kaiser is being so lackadaisical?
5) What should we do now?

Any and all responses are very much appreciated.
- Sophia

[caregiver222]

First of all, consult an attorney. That's "what you should do now".

It is not possible to find your own way through the workman's comp. system without one. The comp. attorneys tend to be the bottom of the barrel, which is another problem. You might do better with a specialist in tort malpractice.

Although they don't like it, you can generally have any test you want, and as many as you want, anywhere and comp. will pay or reimburse at the hearing.  You will eventually have a court hearing. There is no reason to go through Kaiser.

Secondly, you don't have to take workman's comp. You accept workman's comp coverage as an alternative to a tort action. They never tell the employee this.

Accepting workman's comp coverage is actually a covenant not to sue. The school authorities do not make decisions as to coverage.

The employer is liable for all medical expenses whether or not you accept workman's comp.  They didn't do you any big favor. The connection between the injury and the incident will eventually be determined in court, either before a workman's compensation judge, or if you had pursued this case independantly, a civil judge.

In any event, the important thing is for the clot to go away and your life to go back to normsl.

[sophiarosehips]

Thank you! You've been very informative. This is all very good to know!

[caregiver222]

Workman's compensation is a very interesting animal.

Let's take the case of a nurse who was being driven by an intoxicated hospital employee who crashed the van into a concrete retaining wall in the hospital parking lot. She lost her front teeth.
Foolishly, she wrote this up as workman's comp. Thus, she lost her right to sue (or have a tort action) for a disfiguring injury. And it was such an injury. She lost no time from work, so workman's comp. didn't help her much. She should have not filled out the comp. forms (in this State you don't have to) but instead engaged an attorney.

The law in the states differ.

The workman's compensation policy is held by an insurance company, and they employ physicians whose only interest is to minimize your injury and the costs to the company. They are not your friend. Neither is the workman's comp investigator who will visit your house.

Workman's compensation provides two benefits:

(1) A weekly paycheck. They usually refuse to start writing checks until you agree to go back to work.
(2) A lump sum settlement, which may be considerable.

In general, a person who is injured on the job, who accepts workman's comp, can have his/her choice (within reason) of any conventional medical treatment from any practicioner. You are not limited in any way by your health care plan.

The standard is "the doctrine of the reasonable and prudent man".

Any treatment that is reasonable and prudent will probably be approved by the hearing judge.

Workman's comp cases proceed under rules similar to civil court cases. There is a judge, or hearing officer, and you provide information and get to plea for your side of the case. It is very important to go to a physician regularly, even though the pain goes away. When you get in front of that hearing officer he wants to see "medical records".

And, while I would never counsel anyone to fib, the honest patient finds that his off-the-cuff comment that "I'm feeling much better" ends up as a notation "the patient has healed". It pays to keep complaining of the pain.

The other interesting thing they do is try to make you sign a waiver permitting them access to all your medical records forever. You don't have to sign this. What you can do is to sign a limited waiver restricting their access to certain periods of time, and ending on a certain date. And restricting their access to information relating to the on-the-job injuries. You should also add a caveat restricting their access to your psychiatric records.

One question is "do I have to accept workman's compensation".

Maybe yes. Maybe no.

Let's take the case where an EMT is driving an ambulance made by the "Crummy Truck Corporation" and this vehicle has a history of poor design of the brakes, which suffer a catastrophic failure. The ambulance is owned by the hospital. In this case, if he is injured as a result of brake failure and paralyzed, he may have a tort action against the vehicle manufacturer as well as the hospital. If he signs up for workman's comp, he may forfeit his right to have an action against the "Crummy Truck Corporation". I say may. But I would consult an attorney before signing that workman's comp claim. Accepting worman's comp is a "covenant not to sure".