Future Medical Care Apportionment (between carriers) (Califo

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Future Medical Care Apportionment (between carriers) (Califo

Postby wcadjuster on Tue Nov 03, 2009 11:03 am

Hi All, Think this is my first post since the new forums went up. Doesn't seem to be nearly as active as the legacy forums, but here goes.



I need a little input and any citations that you all may think is relevant. I think I've included all the information that is necessary to provide a complete picture.

Background: Two specific DOI to the same/similiar bodyparts, there are separate and distinct insurors for each DOI.

1st DOI - 7/02
2nd DOI - 7/04

There is a PQME on record dated 11/06, the report addresses both injuries. The Panel was requested based on the objection of the IW to the orig. 2% WPI given by PTP.

WPI given was 10%, of that, 60% of the disabiility was apportioned to pre-existing/degenerative changes. FMC included up to a total knee replacement.

Carrier for the 2nd DOI requested a supplemental report from PQME and one was issued 3/07. In it the physician indicated that 30% of the industrial permanent impairment is related to 7/02 injury and 10% due to 7/04 injury. He goes on to indicate that because the second injury caused so little in way of PD, he attributes the future medical care need to ALL of the the 7/02 injury.

Or put another way, of the 10% WPI, 4% is industrial. Of that 4%, the first injury is 75% responsible and 25% is for the second injury. But the physician then attributes 100% of FMC to the first injury, does that sound right?
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Re: Future Medical Care Apportionment (between carriers) (Califo

Postby postscript2 on Wed Nov 04, 2009 2:43 am

Was the '02 DOI ever settled via a Stip? I ask because the 5 years to file for new and further would have expired along with the 1 year to file an application under the statutes. If not, was the I/W ever at any time declared MMI for the '02 injury? When was the MMI date for the 2nd injury?

Were there two separate employers? OR, two carriers for the same employer?

It seems a bit odd that the FMC would be apportioned 100% to carrier #1, just based upon the disability--but it does happen. I would seriously question what FMC if any was indicated from injury #1 by the original PTP. Compare this to the "findings" of the PQME to see if it makes sense. Was there a huge treatment gap between injury #1 and injury #2???

On which claim, did the I/W request a PQME??? Did the C/A for injury #2 cc ALL PARTIES with their letter to the PQME? I'm not so sure that the PQME is "binding" on both carriers, especially if there was ZERO P.D. from injury #1.

I am guessing that you work for ER#1... AND a total knee replacement is not cheap. Also having to reserve for this will be a huge surprise for the ER.

Finally, if the I/W was MMI prior to the end of 2004 (SB899), for either or both of the injuries, then the old PDRS would apply. Perhaps the original 2% was for subjectives??? Lots to think about, dependent upon which ER or date of injury you are adjusting for.

So there is a lot of "food for thought" here. Perhaps if you provide a little more information, I or some of the others can help out more.

Welcome to the new forums--I too have noticed many folks have not posted since the change. Hopefully it will increase with time. Good luck,

LCS ;)
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Re: Future Medical Care Apportionment (between carriers) (Califo

Postby wcadjuster on Fri Nov 06, 2009 11:08 am

Was the '02 DOI ever settled via a Stip? I ask because the 5 years to file for new and further would have expired along with the 1 year to file an application under the statutes. If not, was the I/W ever at any time declared MMI for the '02 injury? When was the MMI date for the 2nd injury?

Were there two separate employers? OR, two carriers for the same employer?


No finalization of anything, at any time. Same employer, different guarantors (it is a large deduc. plan, so regardless, it's the ER's money no matter what "pocket" it comes out of). New PDRS applies based on MMI date.

Is a situation where LC 3208.2 applicable in this case? Is there a bright-line example of what/when this LC would apply?
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Re: Future Medical Care Apportionment (between carriers) (Califo

Postby stewshe on Fri Nov 06, 2009 12:56 pm

wcadjuster,

Responsibility for future medical treatment is very fact specific. For example, suppose EE had their left leg amputated above the knee in the first injury and in the second the EE's leg was bumped, causing pain, TD and a need for treatment....for a few months, but EE then returned to pre-2nd injury condition.

Clearly, the 2nd injury should not be responsible for all or part of future leg prosthesis (plural??), etc.

Now, reverse the facts. The first injury is minor and while healing from that injury, after returning to EE's U&C, but not yet "MMI," the EE has a MVA on a super rush "special mission" delivery of flowers to the boss's wife on their anniversary, at the boss's request, the EE has an MVA and EE's left leg is amputated.

Again, clearly, the 2nd injury should be responsible for future treatment due to the amputation.

There are no hard and fast rules for which injury pays. It depends on the facts and especially the medical evidence.
James T. Stewart (stewshe@comcast.net)
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