Company Cuts Off Injured Woman's Workers' Comp Benefits After Two Years
By James M. Hoffmann
Aug. 16, 2013 11:41a
One Fresno company is in the spotlight for not providing medical care to a woman who had been injured while working for the company more than ten years ago. This case is being used as an example of systematic problems with the workers’ compensation system.
Guadalupe Ortega, the injured employee, and her attorney, held a press conference to discuss her case. The press conference was held by the California Applicants Attorneys Association, and took place directly across the street from Lyons Magnus, the Fresno food processing company where Ortega had formerly been employed.
Lyons Magnus and their doctors confirmed that Ortega was injured and these injuries were work related, Sedgwick Claims Management Services, the company’s insurance carrier, only provided Ortega with 2 years of disability compensation. Orgeta was deemed as 70% disabled by a qualified medical evaluator, but she says that the company still cut off her temporary disability benefits after only two years.
Ortega’s attorney says that the issue of injured workers running into countless roadblocks when trying to obtain workers’ compensation benefits is a statewide problem. "Unfortunately, her experiences are not unique in the workers' compensation arena," he said.
Guadalupe Ortega’s life was very negatively impacted by the severe neck, shoulder, and back injuries she sustained at work. After becoming injured she then lost her job, became homeless, and as a result, her children were taken away. She says "Sedgwick has turned my life into a living hell. How can the state of California allow this insurance company to fail to pay legitimate claims?"
Sedgwick is based in Memphis, Tennessee and refers to itself as the leading North American provider for claims management. The company did not respond to requests for comments.
Eight and a half years ago California passed a law that reduced the penalties that insurance companies are responsible for when they fail to pay benefits to workers in a timely manner, Ortega's attorney explained. This means that there is far less incentive to abide by the law and pay claims out to injured workers. The government offers very little help or oversight, and this just harms injured workers even further.
The medical evaluator and physician who originally examined Ortega agreed that the 2005 law makes it more difficult for injured workers to receive workers’ compensation benefits and appropriate medical care. Prior to this, insurance companies were not able to deny the care that physicians recommended without real medical evidence, but a process called “utilization review,” made denying claims much easier.
The doctor went on to say that the 2005 law was an attempt to correct the fact that care was being overused. Instead of correcting the problem, "utilization review” just shifted the power balance to favor the insurance carrier.
After a claim is denied by an insurance carrier, the injured worker needs to appeal the decision by seeing a certified medical evaluator. This is their only legal remedy.
The woman's attorney hopes that he and Ortega can convince state officials to hold Sedgwick accountable and for an investigation to take place.
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