Nurse Case Manager Misconduct
Have you been hurt at work and the insurance adjuster assigned a nurse case manager to accompany you to your medical appointments?
We represented a worker who had a nurse case manager attend all doctor’s appointments with him. A nurse case manager is a nurse who is supposed to take a look at a workers’ compensation claim from a broad view, considering both the medical and legal aspects of the case. Some of the duties of a nurse case manager include:
- Schedule appointments
- Act as a liaison between the injured worker, medical provider, employer and workers’ comp benefit provider
- Ensure the doctor keeps the employer/insurance agency informed of recommendations including work restrictions
- Help facilitate care suggested by the medical provider
Before the nurse case manager’s involvement, the injured worker felt like he had a good relationship with the doctor that was treating him…until the nurse case manager came along.
Once the nurse got involved, the client felt that the doctor treated him differently and that the nurse controlled the medical visits. The doctor would defer to the nurse regarding treatment choices, such as authorizing an MRI and even the PPI.
The Indiana Workers’ Compensation Act does not currently regulate the conduct of nurse case managers. However, if a nurse acts improperly, that can result in sanctions being issued against the insurance company. We have seen nurse case managers that attempt to manipulate the medical care being given to our clients. Instead of helping the injured worker recover from his injuries, the nurse case manager is acting in the best interest of the insurance company to cut off your medical care and benefits.
If you have a situation where a nurse case manager is controlling your medical care, we can help. Call us at (317) 569-9644. Don’t let a nurse case manager impact your medical care, get the treatment and rehabilitation you deserve.
Personal Experience With Unfair Treatment of Injured Workers
As an attorney, I see many cases where adjusters and employers are fair and try their best to follow the law. However, I see cases where adjusters and employers try to skirt the Indiana Workers’ Compensation Act laws at every turn.
The more I practice law, the more I feel like employers, in many cases, look for any reason to take advantage of injured workers. Two recent examples really make me wonder about what rights injured workers may have.
In a recent case, my client, an employee of a nursing home, was injured at work and offered light duty which consisted of remaining at the nursing home for a period of 13 hours a day and working three separate work shifts with 2-3 hour breaks in between. I truly feel that the employer designed this offer of light duty so that she would refuse it, then lose her job and not be paid workers’ compensation benefits. The employer later modified this offer of light duty to include only 3 hours a day of work. My client lives 25 minutes from this nursing home and to work 3 hours a day after taxes would put approximately $35 in her pocket a day. I assume gas money would probably cost 1/3rd of that amount.
Another scenario I saw recently, and I see all the time, is an insurance adjuster or an employer ignoring treatment recommendations of doctors they select. Under our Indiana Workers’ Compensation Act, an employer is allowed to select the physician, but is required to provide the treatment, medical services or supplies recommended by that physician. An adjuster or an employer is not free to pick or choose what it will authorize or what it will not.
Does the Indiana Workers’ Compensation Act protect my job?
Unfortunately, the Indiana Workers’ Compensation Act does not protect or secure an injured worker’s job after a work accident. The Act only bars an employer from firing an employee in retaliation against him or her for filing a workers’ compensation claim.
It is your right to pursue a claim under the Workers’ Compensation Act. However, injured workers sometimes find themselves getting written up or reprimanded for issues that would not have been a big deal in the past, once they do return to the job after a work accident. These issues may serve as a basis for the employer to fire the employee at a later time, or the employer may push the injured worker to feel like he or she should resign.
If you find yourself in a similar situation, you should consult with a qualified Indiana worker’s compensation attorney.
Social Security Disability & Workers’ Compensation
Sometimes, workers sustain a work injury that leaves them unable to return to their former job or a similar job. Since permanent total disability (PTD) benefits are not a guarantee for an injured worker who cannot return to his or her prior job or place of employment, these individuals might be forced to seek benefits elsewhere.
Consequently, social security disability (SSD) benefits may be pursued by the injured individual. This often leads to the question of whether SSD benefits will be reduced if the worker is also receiving TTD benefits from workers’ compensation. To determine if there will be a reduction in SSD benefits, a specific formula needs to be followed. Here is how you can determine whether your workers’ compensation benefits will affect drawing social security pay early due to a work-related disability:
- If the total of your combined monthly workers’ compensation and social security benefits (including what others in your household draw) exceeds 80% of your gross average earnings per month (average current earnings) prior to the disability, then your SSD benefits will be reduced so that you do not exceed this 80% level
- Example: Donna draws $1,000 from SSD per month. Her husband draws $1,500 per month. Donna is also drawing $548 from workers’ compensation each month. Thus, benefits in this household total $3,048. Donna’s gross average earnings per month before she became disabled from a work accident was $3,500. Since 80% of $3,500 equals $2,800, the amount that Donna and her family draws from SSD will have to be reduced by $248 (the difference between $3,048 and $2,800) in order to meet the 80% requirement.
OR
2. If your monthly social security disability pay alone is more than 80% of your gross average earnings per month prior to the disability, then your SSD benefits will be reduced so that the combination of drawing these events along with workers’ compensation benefits does not exceed the amount over 80% that you drew just through SSD income.
- Example: Dennis draws $1,300 from SSD per month, while his son draws $300. In total, Dennis’ household receives $1,600 from SSD each month. This does not account for what Dennis earns from workers’ compensation. Dennis’ gross average earnings per month prior to the disability was $1,800. 80% of $1,800 equals $1,440. In this case, since the SSD benefits are more than the 80% requirement, the $1,600 will serve as the maximum standard of benefits level. Thus, the SSD benefits will be reduced so that the combination of this plus Dennis’ workers’ compensation benefits does not exceed $1,600.
On the other hand, workers’ compensation disability pay will not be part of the earnings that determine what you can get from social security disability when you do become eligible to draw it. In other words, if you had a work accident in 1992 and you received 11 weeks of temporary total disability pay that totaled $2,500, then the Social Security Administration will not recognize the $2,500 as part of your total earnings for 1992. This is because social security taxes are not taken out of workers’ compensation disability income.
What if I do not accept my PPI Rating?
It is important to note that the injured worker does not have to accept the worker’s compensation doctor’s permanent partial impairment (PPI) rating. YOUR RIGHT as an injured worker is to negotiate a higher settlement if you think the injury is serious enough that a second opinion from another specialist would likely result in a higher PPI rating.
Here are some things to consider when deciding if you should negotiate the PPI rating:
- Did my injury require surgery?
- Is my injury an aggravation of a pre-existing injury?
- Does the pain from the injury affect other areas of my body?
In this scenario, if you responded “yes” to the first or third question listed above, then negotiating might be a valid option for your claim. In the second question, after factoring out the old injury from the new injury, you may or may not be left with a higher rating to negotiate.
Rules of Thumb
Generally, if you are given two PPI ratings for the same injury from two different doctors, the settlement offered should be the difference (or average) of these two ratings.
On the other hand, if you are given two separate PPI ratings because you injured two different areas of your body as a result of the work accident, then the doctor will probably combine these impairments into one whole body impairment rating.
Hearings
If a dispute over a PPI settlement is not resolved between the parties involved, then the matter will be presented before a Judge. For all practical purposes, it is best if disputes over PPI ratings and settlements can be resolved without a hearing as each Judge rules differently in these matters. It is possible that the Judge will decide in favor of the lesser rating.
Court of Appeals Rules Independent Contractor’s Death Already Properly Compensated
The Indiana Court of Appeals determined that the estate of an independent contractor who died after falling off a ladder has been properly compensated through the state Workers’ Compensation Act. Therefore, the estate cannot claim at a later date that his injuries occurred outside the scope of employment.
The Indiana Court of Appeals has determined that the estate of an independent contractor who fell off a ladder and died was properly compensated through the state workers’ compensation act, and the man’s estate cannot later claim that his injuries occurred outside the scope of employment.
In The Estate of Donald Eugene Smith v. Joshua Stutzman d/b/a Keystone Builders, No. 43A01-1103-PL-136, an appellate panel affirmed the judgment of Kosciusko Superior Judge Duane Huffer in dismissing the estate’s lawsuit against Keystone Builders.
Eugene Smith, who worked for Keystone Builders, broke his neck and died when he fell 20 feet from a ladder in March 2010. Smith’s widow and estate agreed that Smith’s workers’ compensation claim would be settled for a lump-sum settlement of $100,000. In October 2010, however, the estate filed a complaint against Joshua Stutzman, alleging that Smith’s death was the result of Stutzman’s negligence in maintaining a safe workplace. Since Smith was an independent contractor and not an official employee, the estate argued that the claim was valid.
The trial court entered a default judgment against Stutzman, but ultimately dismissed the case in Stutzman’s favor because the Worker’s Compensation Board has exclusive jurisdiction.
Applying its own caselaw about workers’ compensation coverage, the appellate panel also relied on Sims v. U.S. Fidelity & Guar. Co., 782 N.E.2d 345, 349-350 (Ind. 2003), in which the act’s exclusivity provision bars a court from hearing any common law action brought by an employee for the same injury.
On the issue of whether Smith was an employee, the parties agreed to resolve those differences via a settlement agreement.