Here is the direct evidence from my own claim. I can provide complete documentation of every detail I am submitting. My
only request is that you read this entire story. It is long and it has been very difficult to write. It's hard to expose
such personal things about myself, but there is so much at risk here. Therefore, if I can expose myself and all the
explicit details, I am expecting you to read this in its entirety.
I will give you a brief summary of my claim, tell you some things, and show you exactly where the money goes in comp,
exactly who and what is driving up the costs. If you don't want the documentation from me, you can check the files at the
Division of Workers Compensation and see for yourself.
The Beginning
One night after I had pulled a double shift, I shut down the plant and locked up. On my way home I was assaulted by three
employees who worked for the company. I received massive injuries. I was bruised from head to toe but because of the
delays in the comp system, it took years to get properly diagnosed and get some of the treatment I needed. I have been told
by just about every doctor I have ever seen that if I had gotten immediate medical treatment I most likely would not be
permanently and totally disabled today. Imagine the cost savings that the carrier would have accrued since my injury.
I originally filed my claim under my regular health insurance thinking that was the place it should be filed. The Director
of Human Resources at my job instructed me to file a comp claim and put all my treatment under that, and I did.
A couple of years went by and after attempting to return to work on three separate occasions, my employer said I could not
do my job at even a sedentary position and I was taken off work. My employer contacted my doctor and both agreed I was
unable to perform even sedentary duties. I was forgetting things, falling asleep at work because of the 16 different
medications I took and was having difficulty learning new things.
My Diagnosis
I was then sent to a neuropsychologist for neuropsychological testing. There it was discovered that I also had damage to
the brain stem and frontal lobe damage that affected my cognitive abilities. I have short term memory loss, some loss of
motor skills, loss in visual and verbal reading skills, loss of organizational skills, and many more cognitive deficits.
Permanent and Totally Disabled
Not PTD? First Litigation. Benefits Unjustly Cut
I was going to doctors five days a week and sometimes more except for when I was in the hospital which was often. Now I go
at least four times a week most weeks. During all this time I stayed in the house going out only for doctors' appointments
and only for what I considered a 'must'. I was afraid of people. I had no friends and didn't want any. I did most of my
shopping through catalogues so I didn't have to go out in public. My daughter or family did most of my grocery shopping.
My cognitive therapist was working with me to learn to use different parts of my brain to take on functions of the damaged
areas. She also continues to work with me on adapting techniques so that I can function more normally. My psychologist was
working on my psychological issues and both of those doctors were working with fear and trust issues, trying to slowly get
me out of the house for short periods of time.
Benefits Cut Again. More Attorney Costs
Lost Everything, Unjustly. Judicial Delays
Unfortunately for me, the employer/carrier appealed the case. Under Florida law, the benefits awarded need not be paid
while an appeal is pending. Resolving this took another year and a half to get through the courts. The appellate court once
again ruled in my favor on December 31. The carrier had 30 days to pay the back money they owed me.
Unlawful Delays By Carrier.Refusal to Comply with Court Order
My attorney called the carrier's attorney and the money finally came somewhere in the beginning of March.
However, they did NOT pay the penalties for paying it two months late as mandated by statute. Even though the law clearly
states that they had to do this, they refused.
Penalties Unenforceable
Since the Division of Financial Services cannot enforce the law, it left me with no other option than to again file a
petition for benefits. Believe me, the DFS tried very hard to resolve this issue but there is only so much they can do
without the power to enforce the law. This should have never have had to go to court but it did. After another two years
in litigation, I settled this one issue at much less than what I believe they owed me in order to get the issue resolved.
That is, if the carrier honors their agreement that they made before the judge. Truthfully I have little faith that this
carrier will honor anything. Will I have to file another petition for benefits to force the carriers to comply with the
current judicial order?
Who is driving up the cost here? Is it me or the carrier?
A Done Deal. Why Contest It?
Who is driving up costs here?
Time and Money Wasted Through Lack Of Preparation
Who is running up the cost here?
Another Petition for Benefits. Or Two
But, now once again I will be filing a petition for benefits and heading into litigation and the mess starts all over
again and you are the people who are allowing this to go on constantly in the comp system for the more seriously injured
workers. Two or three years from now I will write you and tell you of the outcome of my case. Two or three years' justice
delayed is justice denied.
Presently, in spite of having the Judge of Compensation Claims and also an appellate court rule on the amount of pay I was
entitled to, the carrier has once again lowered my indemnity checks. Additionally, they have refused to allow a much-needed
referral to a specialist from my treating physician (who was selected by the carriers, by the way), and they continue to
send me on unnecessary and meaningless IME's for no other reason than they want to find some doctor to disagree with mine.
How many times do these guys get to take you or force you to court? How long do they get to starve out a disabled person?
How much 'doctor shopping' are they allowed to do?
Who is driving up costs here?
EAO Has Limited Power
What is driving up costs here?
This Last Year
Carrier Harassment
Who drove up the cost?
Next I had heart surgery, not workers comp related. However, while I was still in the hospital, the carrier set up a 6
hour IME for me. I came home from the hospital on Sunday and the IME was on Wednesday 3 days after I came home from the
hospital. This seemed to be unusually curious timing. I called the EAO office to see if they could get the carrier to move
the date because I wasn't up to it. The EAO office requested a change, but the carrier refused them, too. The carrier said
I must go or my benefits would be cut off even though I had been out of the hospital for heart surgery for only three
days! My cognitive therapist, who had been out to my house to give me my meds and check on me on Monday, wrote a note and
sent it to the carrier saying that in her opinion I was not well enough to attend the appointment. The carrier told the EAO
office that she didn't get anything from my cognitive therapist and then she looked and said she did. She then said my
cognitive therapist didn't say I was not up to the appointment in the note but that it said I said I wasn't up to the
appointment in the note, so I had to go. She deliberately lied to the EAO person. I faxed the EAO person a copy of the note
who then called the carrier back. The adjuster still said I had to go. Finally I called my attorney and told him the
situation.
He called the adjuster who told him I had to go or my benefits would be cut off. She also told my attorney she didn't have
any note but he knew she did because he had also faxed her a copy of the note. She finally admitted to having the note but
still insisted I go to the appointment or my benefits would be cut off. My attorney told me not to go.
He talked with the adjuster and gave her the required advance notice the law requires if I can't attend an appointment they
set up. She still said I had to go even though we had complied with the law. The day before the appointment, the doctor's
office called me to verify I was coming to the appointment. I told them that I couldn't make it and that they should have
been notified. The adjuster had told him I had better make that appointment. The next morning, the day the appointment had
been scheduled, I got a call from a transportation service that they were sending out a car for me. I told them I didn't
need a driver because there was no appointment. A car pulled up which I had not requested. They were there to take me to
the appointment. I told the driver I had canceled the appointment. The driver called his boss who said he had called the
adjuster who said I had to go to the appointment so to send out the car. He told the driver that he was told by the
adjuster that he was to send out a car and I had to personally refuse the transportation before he could come back.
Result: someone had to pay for the driver and the cancellation fee for the appointment. I had done what the law required so
who is driving up the costs in comp here?
Now let's talk about other costs.
Medication Go-Betweens
I used to get my meds at a local drugstore. So there was just my cognitive therapist, my doctor, and the drugstore involved.
Then I got a letter saying I had to receive my meds through the mail. I started getting my meds through the mail. Then I
got another letter saying that the carrier was having a company called Total Medical Solutions order my meds. It was their
job to reorder the meds when it was time. So now when there is a problem with my meds I have to go to several people at
different companies to get it straightened out.
This is how it works. Total Medical Solutions calls my doctor for a prescription when it is time. They then call Orangebelt
Drug Mail Services and place the prescription order. The pharmacy calls the adjuster to get approval for the meds. Then
Orangebelt sends me the meds. So now to get my meds taken care of, the process has to go through my doctor, my cognitive
therapist, the adjuster, Total Medical Solutions, Orangebelt and a delivery service.
How is this cost effective?
Who Is The Doctor Here?
Often I used to call the adjuster to tell her she was sending me meds that I didn't take on a regular basis every month and
more often than I needed them. She told me that I had no say in my meds and that she would decide what medicines I need and
when. The end result is I'm getting medicine I don't need and probably won't ever use. My cognitive therapist keeps it and
sends letters on it but often it takes months to straighten it out.
How is this cost effective?
Layers after Layers in Billing
My bills are consistently for the same amount. I see the same two doctors who provide consistent and unvaried services four
days a week for the exact same amount of time. That is unless I am in the hospital or they are on vacation or something
comes up such as illness. This is year round. I see my general practitioner once a month to review meds in order to get my
prescriptions ordered. You would think with that there would be no need for the carrier to have someone review the bill
before they pay it. Not true with this carrier. Even with this routine they still often send the bills on to Medsights for
review. Who is paying for that?
A Useless Test
Presently, the carrier has scheduled what they call a comprehensive functional medical evaluation. I really don't have a
problem with this test except that it is an exhausting test that takes four to six hours, it's stressful, it costs on
average around $800 to $1,000, and there is nothing in this test that addresses the reason I can't work. Remember, my most
disabling injuries are cognitive and psychological. This evaluation covers neither.
So my attorney asks the defense attorney why they are giving me this test. They say because they are entitled to an
evaluation every year for people on PTD.
Let's review. They have chosen all of my doctors, sent me on IME after IME and there are monthly reports that say I still
cannot and will not be able to go back to work ever. I have been in the hospital 9 times this year with an average of a
five-day stay and all the stays are related to my work injury with the exception of the heart surgery.There is a large body
of documentation and an appellate court ruling stating that I am PTD.
I don't know about you but I think $800 to $1000 is a lot of money to pay for a test that doesn't address any of my
disabilities. It will provide them with no useful information for any useful purpose other than perhaps to inconvenience
and harass me or perhaps to pad the pockets of some cronies. I can understand having such an evaluation every year maybe,
if my doctors say there is a change in my condition, but to have an evaluation just for the sake of having an evaluation
and especially one that doesn't address my disability makes no sense to me even if the law says the carrier is entitled to
one a year.
Who is paying for this cost? And why?
Doctor Shopping by the Carrier
In the packet it says this is a Functional Medicine Evaluation ordered by the adjuster. It is to be done at Northeast
Florida Occupational Health Clinic in Orange Park, Florida. That is close enough to Jacksonville. It says the evaluation
will take four to six hours and I will be seeing a Dr. Michael Webb. The paperwork says Dr. Michael Webb in care of Dr.
Chappa.
I call the center to confirm the appointment and ask to speak with someone on Dr. Webb's staff. They say we don't have a
Dr. Webb. I ask them if they are the Northeast Florida Occupational Health Clinic and they say yes. So I ask if there is
a Dr. Chappa there. They say no. Then they say they do have a Dr. Chappa who works out of another center but that he
doesn't have an office or a staff at the clinic. So I say I am scheduled to have an evaluation there on Wednesday. I give
her my name. The receptionist checks her schedule book and says wait a minute. We are bringing a doctor in from another
area of the state to do this evaluation and Dr. Chappa is coming over here to oversee it. I say why would you do that?
Don't you have any doctors that do that there and that take comp? She says yes but the adjuster wants you to see this
doctor. Now who is paying for this? Doesn't this sound just a little odd or even suspicious in light of the rest of my
history with this carrier?
Okay, so now we have an injured worker who lives in Jacksonville with a carrier based in Orlando who calls a company in
West Palm Beach to find me a doctor in Jacksonville. Add to that the doctor is not even in Jacksonville so that means they
are paying his traveling expenses and possibly motel room and most likely an extra fee to have him come up here and have
another doctor that works in another facility go to this closer facility to supervise the other doctor while he gives me
an evaluation.
In other words, the local clinic which is qualified to do the test is required by the adjuster to bring in at their
regular fees plus additional costs for travel and consultation one out-of-town doctor and one doctor from across town to
perform an $800-$1000 test that is guaranteed to provide no useful information nor will it address the conditions that
prevent me from working.
How much is this costing? Who is paying for it? Who is really driving up the cost in the comp system? Is it possible that
these companies are colluding for profit? Why in the world would someone do things this way and expect it to be cost
effective?
No wonder they say they aren't making a profit. No one could make a profit running a business this way. How can a company
operate like this and then turn around and complain about not making a profit?! And get the legislature to pass laws
assisting them?
This is inhumane, unbelievable, unreasonable, unacceptable, not cost effective, and cruel, and you have given these people
the power to get away with this time after time with all the favorable legislation you have passed over the years. This
year you gave them even more power and took away the only power that injured persons have to fight with.
Who will stop this runaway train and when?
This is not something that just happens to me. It happens to just about anyone and everyone that has any kind of serious
and long term injury. It happens on a regular basis in all parts of the state and all parts of the country. Same song,
different verse.
My Exhortation
Now that you have finished reading this, do you still believe that the cost driver in comp is anything but the carrier? If
you don't, then perhaps you should pull the files on every long term and seriously injured claim.
You will see the same thing over and over again. Open your eyes.
It needs to be said that as of Oct. 1, 2003, the Division of Financial Services has been given statutory authority to
examine and investigate carriers and claim-handling entities (F.S. 440. 525). 'If' the department finds the claims handling
entity has engaged in patterns or practices that violate the law, the department may impose penalties. Sources at DFS have
indicated to me that DFS intends to use this provision. We applaud their actions and gratefully note how much more
assistance we have gotten from DFS in the last year and a half. Because of their interaction with DFS, some injured workers
have had successful resolutions of their complaints without having to resort to litigation.
DFS has the authority to investigate and to levy fines but there is still no way to actually enforce the law! Give someone
the power to enforce the law and press criminal charges against the insurance companies when these conditions exist, but
first -- this runaway train has to be stopped! Do the job you were sent there to do.
Fix the law, then enforce it. You, not special interest group lobbyists, are supposed to be our leaders. You are supposed
to write the laws to protect and defend the people of this state. The laws written by lobbyists and passed by the
legislature are hurting business and injured workers.
Please evaluate the laws you passed last session and look at restoring rights to injured workers. Restore the only power
injured workers have to fight the arrogance of the of the scofflaw carriers. We, all the citizens of Florida , need your
help now, today.
Mary Bailey
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