Today’s blog is about which insurance company should pay for a surgery and how doctors control the issue of causation without even knowing it or considering how it can affect the patient. Keep this in mind as you read today’s blog: Working people with little education aren’t trained in medicine. This is a limitation patients have that must be kept in mind when doctors take charge of a patient’s care.
Doctors always have to keep in mind that when taking an H&P, they being the educated ones can make or break their patient’s right to receive proper medical insurance coverage by not asking the right questions. So let’s get to today’s issue by examining what I’ve recently seen in my practice. A man comes in with a question about what he should do because the money is running out. He has a condition named spinal stenosis, had surgery at L4 – L5 and it’s been months since he’s worked. The surgeon did the corrective surgery and nicked the spinal cord so the guy is not healing very fast and won’t be going back to work anytime soon. From the patients standpoint it’s a problem; and one he had nothing to do with prolonging. His wife is anxious about how they will put food on the table and uncertainty clouds their future. This patient and his wife, now wanting to be my clients, have a sense life is spinning out of control with no clear path out of this mess. For me they have one question: What can we do? [Are you beginning to see what we PI lawyers do that is so important? No? Well, you’ll get it soon enough.]
Spinal stenosis - Spinal stenosis is narrowing of the spinal column that causes pressure on the spinal cord, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column.
First, spinal stenosis is normally a slow developing condition. It’s a condition that takes a long time to develop and then to become a significant problem. And when it becomes a problem, it's a big one.
Second, work probably didn’t cause it as much as the work aggravated, accelerated or lit the condition up.
And that’s all you need to make this a workers’ compensation case. If the work aggravated the condition or accelerated the condition or lit the condition up then I can establish legal causation.
This guy does extremely hard work and has done this work for more than five years. The work is a lot of lifting, using pressure hoses and swinging his torso. He’s built like an ox, a big man with powerful hands that swallowed mine when I shake his hand. I can feel the power in his forearm as much as I can see the worry on his wife’s face. I immediately like these people; they are salt of the earth, hard working Americans with a sense of wanting to live honestly through hard work and cheating no one. Today all they want is a fair shake and the answer to where their next meal will come from.
But here is the problem I see. The doctor never considered if this were a work related medical condition that should be covered by workers’ compensation insurance. He never asked even a single question to determine in the H&P, if this is work related. He should have, but he didn’t. Instead he let the coders file this under the health insurance policy. Health insurance doesn't cover work related medical care because that's the duty of the workers' compensation system.
As I learn more about this man's spinal condition, the surgery, the work and the medical history I’m drawn to the question about causation, what caused this man’s condition or did the work aggravate or light-up an underlying physical (medical) condition that required surgical intervention? It appears obvious to me the causal link is there, but the doctor never considered it. Why not?
What the doctor didn’t consider is going to cause problems for his patient’s legal case. Why? Because the legal case requires me to prove causation; meaning, did the physical work cause, aggravate, accelerate or light-up the spinal stenosis requiring surgical intervention? That’s a preliminary question of this case and if I can’t get it answered we’re going nowhere fast. As I pointed out I like these people, they are nice hard working and honest people.
Symptoms - Often, symptoms will get worse slowly over time. Most often, symptoms will be on one side of the body or the other, but may involve both legs.
- Numbness, cramping, or pain in the back, buttocks, thighs, or calves, or in the neck, shoulders, or arms
- Weakness of part of a leg or arm
Symptoms are more likely to be present or get worse when you stand or walk. They will often lessen or disappear when you sit down or lean forward. Most people with spinal stenosis cannot walk for a long period of time.
Patients with spinal stenosis may be able to ride a bicycle with little pain.
More serious symptoms include:
- Difficulty or poor balance when walking
- Problems controlling urine or bowel movements
You probably are thinking, well just ask the doctor, and yes I will, but why wasn’t it asked before the surgery was undertaken when questions of insurance coverage (who should pay for the surgery) were front and center. At this point, months after the surgery, it can appear as though the lawyer is just getting creative rather than the doctor seeing the forest for the trees. (Did I say that right? I should never try and be creative at 5:00 a.m. before the second cup of coffee.)
So here is today’s bit of legal advice to the surgeons out there. Before you take out the scalpel, how about first you take ten minutes out of your day and ask the right questions when doing the H&P. In this case you needed to know a bit about the work history and the medical condition to arrive at a credible conclusion about causation before billing forms were filled out. Yes, the condition exists and yes it needed surgery. And no I’m not suing you for nicking the spinal cord, so get your head up and listen. Surgeons need to understand that although this is a congenital or slow forming condition not originally caused by work, it is a condition that is lighted-up or aggravated by heavy work and as such it is covered under workers’ compensation (not the health insurance policy).
Do you know why aging and imperfect workers medical conditions are covered when aggravated by work? Because we are all imperfect medically and if we required workers to be perfect to qualify for workers’ compensation benefits not even you would be eligible. So before making the first cut, ask the question about causation or call a lawyer to ask his advice about who should legally pay for this surgery. Ask me the lawyer for no reason other than the patient and his family go hungry when your surgical technique is less than perfect.
I rest my case.
*Today's photo image I shot and it can be seen on I-90 in South Dakota. The skeleton human is taking the skeleton dinosaur out for a walk through a hay field. Here is a link to the geo markers.