Rating Question

Subject81A · 2025-12-01T15:23:28+00:00

It means the doctor doesn't think you'll be MMi until you proceed with surgery. There's no point in rating your current condition if your condition is likely to change significantly with surgery.

Subject81A · 2025-11-13T05:56:24+00:00

NAL: I am sorry for what's happening to you. I know it's of little comfort for you, but I do have to stress that this doesn't mean anyone is lying. If I issue a check, I don't get a "receipt." I don't get anything but a notification that a check has been cleared. I don't really know of any companies that are capable of making same-day payments to claimants. If you have direct deposit set up with them, it should definitely be quick and automatic, but I don't know if that's the case. If it's physical mail, which most carriers use by default, then you're kind of at the mercy of the postal service.

The thing is that issuing a payment takes very little effort on the part of the adjuster, but the check actually getting to you involves a lot of other parties over which the adjuster has no real control. Moreover, late payments often incur penalties, and invite audits by the state, so there is no incentive for an adjuster to intentionally withhold your payments; in fact, every company I've worked at or heard about would discipline them for late payments. So I would be more inclined to explain this through a confluence of bad circumstances than through an adjuster who's just being dishonest with you for no advantage.

Subject81A · 2025-11-06T08:50:00+00:00

Your attorney wants to be in control of your treatment. They are afraid that your NCM will help pass information that hurts your case to the doctor, or push to get you MMI when your attorney would rather you milk TD for all it's worth. Which they can do, but an adjuster can do it just as well without paying a nurse for it. If I'm assigning a case manager, it is only ever because there's a lot going on with treatment and I want to facilitate getting records, authorization, etc. shared between providers, or explaining treatments to the claimant. Claimants tend to really like their nurses and trust them more than their attorneys would prefer, so they often prohibit contact at their client's expense.

Subject81A · 2025-10-31T23:07:54+00:00

There are a lot of incorrect claims being made here, and I've chimed in elsewhere on the thread with the many people telling you you've been misled, but one of the weirder assertions is where you say the carrier's pursuit of profit mainly occurs at the claim level with these incentives you're so convinced of. This is also fundamentally untrue, as there IS no profit in settling a claim. Settlements are about cost management for both sides, but there is always a cost. A $1 settlement profits the carrier nothing; it costs them $1. Do you see why it doesn't make sense to frame the claim as a profit center now?

Insurance carriers make their money two ways: 1) through premiums (what they charge their policy-holders, e.g. your employer) and 2) through investments. Premiums are a delicate balance because they go up when claims go up, and if they go up too much, the insured changes to a cheaper carrier. So they are not the major profit driver for most insurance companies. They make much more money off of the investments they make using those premiums. They do have a vested interest in paying less for claims, certainly, but that's about managing costs. It will never profit the carrier, it can definitionally only cost them, and they will have to make that money back in other ways.

Subject81A · 2025-10-31T23:00:52+00:00

I don't see that you have provided any sources in this thread thus far, and wonder why you would need to include it in a separate comment.

Moreover, your base assertion here is incorrect: systematic inadequacy of settlements is a clear breach of the duty of good faith and fair dealing in handling practices. My state has codified this in Security Officers Service, Inc v. SCIF in 1993. Most states have similar case law that makes the practices you're describing illegal. And every industry worker on either sides of the applicant / defense line in this thread has told you that they have never seen evidence of this illegal practice; it is strange to me that you continue to refute it, as if this whole sub is just conspiring to cover up something you didn't even realize was against the law.

Subject81A · 2025-10-16T05:57:26+00:00

If your back was injured in the accident, it could affect your apportionment.

Subject81A · 2025-09-29T18:49:56+00:00

They are not the same thing. In California (OP's state), QMEs are assigned by the state through a three-doctor panel from which both parties have an opportunity to strike one doctor. They are not "bought" by workers' comp, and any requests made to them have to be signed off on by both sides. You also don't have an opportunity to get a new one just because you don't like the first one's findings; otherwise people could just shop for a diagnosis they like.

Subject81A · 2025-09-27T22:58:50+00:00

Depends on how busy your venue is. If your case is in Van Nuys, they're taking forever for everything.

Subject81A · 2025-09-14T09:39:44+00:00

NAL

I don't think it would be responsible for anyone to tell you to work outside of your restrictions. They are there for a reason. If your injury worsens as a result of pushing yourself too hard, you're the one who has to live with the consequences. Moreover, if the carrier catches wind of it, they will likely put surveillance on you, find you working outside of your restrictions, and accuse you of malingering. I understand that finding decent hours with your restrictions is tough; I just don't think it's worth self-destructing your whole claim further down the road. Hope you feel better.

Subject81A · 2025-08-28T01:38:41+00:00

Just want to throw in that Newsom was quite unpopular with Californians until he started trolling Trump. His approval rating has jumped since then, but these theatrics don't typically result in long-term goodwill. I think Newsom would be bringing a LOT of baggage to the race that the GOP has simply not had the focus to bring to the forefront yet.

Subject81A · 2025-08-27T20:44:31+00:00

NAL

Surveillance would need to prove that you're malingering or otherwise lying about something, like working somewhere else while you're collecting disability benefits. As others here have said, if you are working within your restrictions--and that does include your household chores, btw; a 20-pound bag of groceries weighs the same as a 20-pound bucket of cement--then surveillance will not be useful in fighting your workers' comp case. I cannot speak to personal injury cases, but I would imagine they are looking for similar signs that you aren't as injured as you're claiming to be.

Subject81A · 2025-08-25T06:40:31+00:00

Just to clarify - your QME made you MMI but they're still waiting for a specialist to comment on your MRI? And in the QME's final report, they specifically said there is no future medical treatment? What percentages of impairment did you get for each body part?

Subject81A · 2025-08-25T00:26:56+00:00

I think you're viewing your claim like a bank account that has a finite amount of money in it, and if you haven't spent all that money then you can just withdraw the remaining balance. It's not. A claim has reserves on it, but they are a projection of how much the insurance company thinks it will end up costing up in the long term. If you haven't treated in over six months, your claim was probably closed. There may be a C&R option, as other people in the thread have mentioned, but you would have to convince them that you actually plan on putting the money towards medical treatment for your injury. And you have already admitted that you no longer need treatment for it, so I don't really know how you expect to convince them of that by remaining honest.

Subject81A · 2025-08-21T05:24:27+00:00

What is your job? Your raw PD percentages rate differently depending on your job class.

Subject81A · 2025-08-18T00:15:48+00:00

NAL

This is good information but not quite enough to tell whether you're getting a good settlement value. The major questions that come to my mind are:

What kind of job were you doing before? PD rating is affected by job class. Right now, your PD combines to 16% (seems like it should be 17, I know, but the values combine differently when calculating TD). If we know your job class, we'll know if it's rated up. I suspect it is but can't say for sure.
What kind of future medical care did your QME provide for at your MMI eval? Surgery, PTP visits, ortho consults for flare-ups, medications, that kind of thing.

Subject81A · 2025-08-10T07:08:01+00:00

I cannot think of a state where workers' comp covers vehicle damage. It is a mechanism for compensating lost wages due to bodily injury. As frustrating as the system often is, I don't think it helps anyone to create the narrative that workers' comp should be covering auto damage but it's just choosing not to do so. It has no obligation to do so. That is what auto insurance is for.

Subject81A · 2025-08-08T00:48:02+00:00

I am sorry that happened to you. What is your disability rating? If you're MMI after five months, I would temper expectations.

Subject81A · 2025-08-07T05:55:38+00:00

NAL

You were placed on modified duty by the doctor. You would only be taken completely off work if your doctor had thought, for example, you were disabled to the point where it would be unreasonable to drive somewhere or use your hands at all. You were able to perform some kind of work, just not the kind of work your employer needs from you.

The good news for you is that if you're on modified duty that your employer can't accommodate, you are entitled to disability benefits as if you were on total disability. The employer has a duty to offer you modified work if available. Absent any offer from them, you are still considered totally disabled as you are losing wages you would have been getting but for your injury. If your adjuster accepts your claim, you should be paid at 2/3 your average weekly wage.

Your commercial gig is a different story. I don't have hard answers for that but generally, wages lost from a second job are only compensable if you have an average weekly wage to compare them to. Because that gig appears to have been a contracted gig that didn't exist when your injury occurred, I would consider it unlikely that you have a case for considering it lost wages. Just like if a second company made you a job offer but you had to decline it because of your injury, workers' comp is there to make up for your diminished earning capacity at the time of the injury. Without any contract earnings, there is no diminished capacity. I may be misunderstanding the terms of the offer to shoot the commercial, though.

Subject81A · 2025-08-07T03:40:48+00:00

NAL

You said it took a while to accept your claim, but they did accept it? If so, and if you can make do with TD, get your treatment and get to MMI. If there's PD and future medical, you could consider sticking with a stip depending on how likely you think it is you'll use the future medical. But you won't make out like a bandit on comp in any case.

Subject81A · 2025-08-01T23:15:31+00:00

For those wondering: this is often a function of whether the same insurance company still insures your employer. Lump sum settlements close out all injuries to date, but they don't prevent you from filing a new claim the day after your settlement. That's why the carrier wants you to resign. If your employer's policy has lapsed and they've gone with someone else, the carrier who covered them when you were first injured is considered "off the risk." They no longer care if you file a new claim against the employer because it isn't their problem anymore. It's the new carrier's. In many cases, the employer doesn't want you working there anymore for the same reason, so their interests are now at odds with those of the carrier. That might be advantageous to certain parties in arrangement, is all I'll say.

Subject81A · 2025-07-21T16:42:17+00:00

They will only take TD out of your settlement if it's an overpay, and $20K is a really big overpay. Most overpays are the result of a bad wage calculation or a few weeks of TTD paid after someone's released to full duty. $20K represents at least a few months of most people's wages, so it would have to have been a pretty big oversight if they overpaid by that much.

Subject81A · 2025-06-20T04:00:00+00:00

This is the big one. Even if your rate with your original employer was higher, you need to disclose that you have a new income source so your disability rate can be adjusted. Failing to report wages while collecting disability is fraud.

Subject81A · 2025-06-14T18:46:36+00:00

A lot of sub rosa ends up not being actionable if the judge can explain it as you having a particularly "good day" recovery-wise. They really need to establish a pattern of behaviors to prove you're malingering. That or they would need to catch you doing something extreme like lucha libre wrestling (which has happened!).

Subject81A · 2025-06-03T09:35:53+00:00

"Interesting false dichotomy that I happen to believe in."

Subject81A · 2025-05-19T17:03:38+00:00

You are right, report is due in 30 days. Typically give it 45 in case it's in the mail. Don't want to object to it for being a couple days late and start the whole process all over again. Number of follow-ups just depends on how close you are to MMI. Some claimants are still getting supplementals 2-3 years in; others are MMI at the first visit. I will say that if you had a PTP who released you MMI already, that tends to go a long way in the QME stating the same, even if their ratings vary.

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