Posted by T. Urtle on March 19, 1999 at 22:55:25:
In Reply to: Re: Reply to T. Urtle posted by Del on March 19, 1999 at 11:38:30:
I agree that it would be a better practice to send Notice of Closures by certified mail, however, I reiterate that a civil penalty can be issued if a closure is not sent. Furthermore, the reconsideration process is not the only legal alternative for pursuing disagreements since a hearing can be requested.
I understand that the money saved by eliminating the evaluations unit will not be transferred to the ombudsman or the appellate unit, but I still believe that you should be advocating for a more efficient system rather than holding onto one that clearly doesn't work. If the evaluations unit was the savior of the injured worker, we would not be seeing all of the problems that you discuss, i.e., a functioning evaluations unit was not able to protect you from not receiving the notice of closure. I think most taxpayers, injured and uninjured, would prefer to do away with an ineffective, inefficient, and inaccurate beurocratic unit even if a perfect solution was not available to replace it.
Unethical conduct by insurance carriers should be pursued in every instance and by every means available. However, the evaluation unit does not have a legal vehicle to be involved in this process and to provide one would be duplicating the efforts of the appellate unit.
I would be interested to understand the basis of your opinion that the appellate unit is underfunded and understaffed. I have not heard any instances of the unit being unable to meet their statutory obligations. Why do you assume that they lack funding and personell?
Furthermore, I don't understand your allegation that it takes months to have a closure overturned. The appellate unit has 18 working days to determine that a closure was premature and an additional 60 calendar days to issue a reconsideration order if the claim was not prematurely closed and an arbiter's exam is scheduled to redetermine impairment. It should be noted that it is the worker's choice to request a medical arbiter and delay the order. If the claim was clearly inappropriately closed, the worker can request a determination based upon the record and the closure would be set aside within 18 working days. I understand that a hearing can be requested after the reconsideration order is issued and this can delay a decision for several months, however, if the closure is set aside the insurance carrier would be required to pay benefits while it appeals the order.
I fail to understand your ascertation that the number of calls to the ombudsman's office correlates to the number of denials issued by the insurance carriers. Clearly, there are many reasons that workers could be calling the ombudsman and, unless you have statistics from the ombudsman to prove otherwise, I doubt the sole issue is claims denial or dishonesty on the part of the insurance carriers. I believe that injured workers and insurance carriers use the ombudsmans office to provide information and education on a number of issues and actual complaints are a small part of the daily work load. If you want a real eye opener, call the ombudsman's office and discuss the number of complaints from workers toward their own attorneys. Or, better yet, ask them how many represented workers that they help each day. I have seen many referrals on this site to and from WC attorneys. However, like any small business person, their bottom line is making money and often times this money is made at the expense of the injured worker. The ombudsmans office is a great clearing house for unrepresented workers to receive truly unbiased information so that they can make meaningful decision for themselves without worrying about the underlying motives of the person on the other end of the line.
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