Insurance companies use Utilization Review (UR) to deny and delay needed medical care. The care is usually recommended by the company’s own chosen doctor. Without consequences or effective penalties, insurers’ UR is out of control. It has real impacts on injured workers.
About Me: My name is Cleveland Waters. I’m 45 years old, and I live in Altadena, in Los Angeles County.
About My Family: I am married, and my wife and I have four children: two girls, ages 17 and 18; and two boys, 7 and 12.
My Job and What Happened: I worked for the Los Angeles County Metropolitan Transit Authority (LA MTA) for 11 1/2 years as a bus operator. I loved my job. I grew up in South Los Angeles, and I knew a lot of the people on my bus route. I played football and basketball and knew many people in the community. I enjoyed serving the people in the community, and I had received commendations for my positive interactions with the passengers. I was proud of my job and of providing for my family. On Oct. 26, 2011, I injured my left knee while trying to secure a wheelchair for a passenger on my bus. When I knelt down to lock the wheelchair in, I heard a pop and felt pain. I reported the injury the next day once I saw it had gotten worse overnight. I had an MRI, which showed a torn meniscus, causing my knee to lock at times.
What this has meant to my life: I have been unable to work for more than three years. I have been waiting for pre-surgery treatment to be approved, but MTA has denied it twice. The two-year cap on Temporary Disability (TD) has run out while the MTA delays and denies the recommended medical care. I have had no substantial income, and am uncertain whether I will be able to return to my job and career. MTA also cut off my family’s health insurance because I’ve been off work for so long. We lost our doctors, and have had to turn to public assistance.
How Utilization Review (UR) Delays and Denials Affect Me: I need surgery on my left knee, but I am at risk of a heart attack during knee surgery. While I have always been a large man, I had always been active. Since my injury I’ve gained weight which I must reduce before the knee surgery. The MTA has denied the treatment I need to allow me to qualify for knee surgery, so I am stuck, unable to have the knee surgery I need. It seems they’d rather see me suffer than approve the pre-surgery treatment I need to have the knee operation, heal and return to work. The longer I’m off work, the less likely I’ll be able to heal and return to the job I love. This is a horrible trap I’m in and has harmed my family as well.
How Workers’ Comp was supposed to help me: Workers’ Compensation was supposed to help me: Workers’ Compensation insurance is supposed to provide medical care necessary to cure or relieve the effects of my work injury. The MTA UR reviewer ignored the medical records from their own chosen medical network physician stating that I have diabetes, which qualifies me for the pre-surgery treatment I need. I have high blood pressure, hypertension and sleep apnea, which also qualify me for the treatment to prepare for surgery. My doctors have pointed out to MTA that I meet the medical guidelines, but MTA ignores the medical evidence without penalty.