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The Fresno Bee
Fresno workers' compensation case highlights statewide problems
By Carmen George
Published: August 6, 2013
FOR IMMEDIATE RELEASE: Wednesday, August 7, 2013 Contact: Steve Hopcraft 916/457-5546, Steve@hopcraft.com; Twitter: @shopcraft
A workers' compensation company is being criticized for failing to provide medical care for a Fresno woman injured on the job more than 10 years ago.
The employee, Guadalupe Ortega, spoke out with her lawyer Tuesday morning during a press conference held by the California Applicants Attorneys Association across the street from her former employer, Lyons Magnus, a major food processor in Fresno.
Although doctors and Lyons Magnus confirmed her injuries are work related, the company's insurance carrier, Sedgwick Claims Management Services, only provided two years of temporary disability compensation — even though a qualified medical evaluator confirmed she is 70% disabled, Ortega said.
Ortega's plight highlights a larger problem for injured workers statewide who have run into more roadblocks over the past eight years to receive workers' compensation, said Ortega's lawyer, Brett Grove of Keeling Grove Law Offices in Fresno.
"Unfortunately, her experiences are not unique in the workers' compensation arena," Grove said.
Ortega's severe neck, shoulder and back injuries resulted in her losing her job, she said. Ortega became homeless, and her children were taken away from her.
"Sedgwick has turned my life into a living hell," Ortega said. "How can the state of California allow this insurance company to fail to pay legitimate claims?"
Sedgwick officials were unavailable for comment. The company is based in Memphis, Tenn., and calls itself the leading North American provider for claims management.
A state law passed 81/2 years ago greatly reduced the penalties that insurance companies must pay for not providing required benefits to injured workers on time, Grove said. There is now much less incentive to pay back claims, and little oversight from the government, he said.
Dr. Douglas Curran, the physician and qualified medical evaluator who examined Ortega, said the 2005 law has made it increasingly difficult for those injured on the job to receive proper care.
Something called "utilization review" was put in place, allowing insurance companies to more easily deny claims from injured workers, Curran said. Before that, insurance companies could not deny care recommendations from physicians unless they had medical evidence to counter, he said.
Before 2005, "care was being over-used and for insurance companies, that was an issue as well," Curran said. "Utilization review was an attempt to correct that, but it shifted the balance of power way into the insurance carrier's power."
Once a claim is denied, the only remedy injured workers have to appeal the decision is to see a certified medical evaluator, like Curran.
Grove said he and Ortega are calling for state officials to investigate Sedgwick and hold it accountable.
For more information, visit www.caaa.org
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