We Need a Hero

Los Angeles, California

Fourteen months ago, Joel took a fall at work and tore the rotator cuff in his shoulder. Since it was a work injury, he was immediately placed on leave under his company's workers compensation insurance. What has followed is too circuitous and, frankly, painful to recount. Let's just say, it hasn't gone well.

My father used to say that if you want something run and done well don't give it to the government. Our experience with workers compensation insurance is that it runs very well, if the object is to insure that no money is expended for the care of the injured. The coverage company, Liberty (yes, that one with the cutesy commercials), denied almost everything that was requested by the physician. The penultimate request was for pain medication, an enhanced plasma injection, some type of ultrasonic/infrared treatment (not too clear on exactly what that was), and PT. They turned down everything except the pain medication.

At each step of the way, doctors, physician assistants, and physical therapists kept asking us if Joel had an attorney. And, finally we got the message and found an attorney. By that time, the osteo surgeon had thrown up his hands and said that the only thing he could ask for, since they turned everything else down, was surgery. The insurance company received the request at about the same time they were served the court filing papers. They approved surgery.

Joel has been in pain for over a year, and while I think he may not have needed, or indeed need now, the surgery had he gotten any of the other treatments requested, he is at the end of his patience on this and just wants to be fixed. And I get that. So, when surgery was scheduled, he was glad and I was resigned. And then...

In preparation for the surgery, an ECG (remember when these were called EKGs?) showed an irregularity. This necessitated a sign-off from a cardiologist, and it was six days before his scheduled surgery. Each day, Joel called the cardiologist's office requesting an appointment, and he was sent back to the referring physician who had done the pre-op exam to fax over an authorization. Finally, the day before the surgery, he again called to request the form. This is what he heard: Well, I guess I could send it over again, but I've already faxed it three times. When he called the cardiologist's office again, they got him in for an appointment and he was subsequently designated as a low risk just twenty-three hours before his scheduled surgery. And, as a result of the 24-hour window closing, his surgery was scratched. And subsequently, rescheduled for four weeks later.

Joel's surgery is scheduled for next week, just a week after his big 60th birthday, which will be just under fifteen months since he slipped on a puddle of liquid detergent, and a month after he stopped working on a limited workload. His employer worked with him. His co-workers worked with him. The only people who didn't work with him were the Workers Comp insurance people.

We hope that the surgeon is the hero in this story, and that he comes through it all well and can return both to work and (more importantly) the dance floor. Then we may need another hero, as I was just diagnosed with a torn rotator cuff! Ok, on what planet does this happen? But in thinking about it since yesterday's diagnosis, I realize that the parts do wear out, and I have spent the last twenty years dancing salsa with my right arm lifted and worked as a lever to turn my body in circles. A bazillion times on scores of dance floors by a multitude of salseros, not all as gentle as Joel. I'm not in that much pain and I can evidently continue working out and lifting free weights, within reason. But I will need to see an osteo surgeon for a more comprehensive diagnosis and treatment plan. The secondary gain and silver lining is that none of this will have to happen through workers compensation. Because in the last analysis, the compensation dispensed in dribs and drabs, is designed to make you give up and deal with your injury outside of workers comp. Clearly, if you want something run really badly, give it to either the government or an insurance company.

My friend, Joan, had to build a gate on her 118-acre property in Santa Ynez. She wasn't completely happy with it, and explained to me that she needed to build one gate to understand the pitfalls and be better able to design the next gate. I think the workers compensation process is a lot like that. You have to go through it once to really understand how it works. Or, as the attorney remarked, how it doesn't work.