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Workman's comp, Aflac, medical issues - need someone with more knowledge than I have


creekland
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I'm well out of my area of expertise, but I know the knowledge is on the Hive somewhere...

 

My sister blew out her knee at work two days ago.  She is uninsured medically, but this was on the job so should be covered by workman's comp.  She supposedly also has Aflac coverage, but I'm not sure if that's paid for by her or her company.  She lives paycheck to paycheck - no emergency fund.  She does NOT live near us or other family.

 

She currently is in a cast with crutches awaiting on paperwork for an MRI.  She can't put any weight on her knee/leg and of course, is in a bit of pain.

 

Aflac is telling her she gets $26.67/day while she's out of work (like that will cover her bills!) AND she needs to pay $26.67/week to keep that coverage while she's out too.  Sure seems like a scam to me, but... I don't know.  I do know I'd never bother paying for Aflac if that's all they do - so potentially a heads up to readers to not buy into their TV commercials.

 

Her bone and joint doctor is going out of town for a week at 2:30pm today.  Can anyone else order the MRI for her knee if that person is gone?  Can anyone else do anything at all or due to her own lack of insurance and being on workman's comp is she "stuck?"

 

How slow can we expect workman's comp to be?  Her injury happened two days ago and she's still waiting...  She's a Fed Ex delivery driver, so there's absolutely no way she can work right now and no work = no pay.

Edited by creekland
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It sounds like she has Aflac’s short term disability coverage which is worthless. I have Aflac’s hospital and accident policies as well which have decent benefits, but still not enough to pay the electric bill like they tout. If she has hospital and accident Aflac coverage she should submit her hospital bills once she has them and they will send her a check. It won’t be enough to live on, but maybe a couple hundred.

 

Workman’s comp takes weeks and then they try to deny whatever they can. They’ll be reasonable about covering her medical bills, but the benefit for being off, in NYs, is something like 2/3 actual pay up to a specific amount. My husband was on comp for a couple weeks and it took three months to get the check for the time he was off.

 

I’m eligible for short term disability starting Monday, after the necessary week with without pay, but for $170 a week it’s almost not worth the hassle of the paperwork.

 

I hope she has a quick recovery.

 

edited: Also since it is worker’s comp, any test that didn’t happen in the ER will need to be first approved by the comp board. My husband has generally had it approved in about seven days.

Edited by MedicMom
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It sounds like she has Aflac’s short term disability coverage which is worthless. I have Aflac’s hospital and accident policies as well which have decent benefits, but still not enough to pay the electric bill like they tout. If she has hospital and accident Aflac coverage she should submit her hospital bills once she has them and they will send her a check. It won’t be enough to live on, but maybe a couple hundred.

 

Workman’s comp takes weeks and then they try to deny whatever they can. They’ll be reasonable about covering her medical bills, but the benefit for being off, in NYs, is something like 2/3 actual pay up to a specific amount. My husband was on comp for a couple weeks and it took three months to get the check for the time he was off.

 

I’m eligible for short term disability starting Monday, after the necessary week with without pay, but for $170 a week it’s almost not worth the hassle of the paperwork.

 

I hope she has a quick recovery.

 

She's in NY.  

 

Yikes... sounds like there's going to be a major financial need soon for her to be able to keep paying bills.  The main problem with that is she never pays anyone back when they loan her money, so it's a larger decision than the obvious.

 

She mentioned having to get a lot of paperwork submitted today - all while in pain and not being able to really walk.

 

I still wonder with her assigned dr going on vacation if anything will even get done within the next week.

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edited: Also since it is worker’s comp, any test that didn’t happen in the ER will need to be first approved by the comp board. My husband has generally had it approved in about seven days.

 

Yikes again.  That's a long time (sigh).

 

I always wish we had universal health care in this country when I read medical stories.  I wish it even more when it's someone "real" to me.

 

Things are just not right in our country.  One gets a legit medical problem and then needs to do tons of paperwork and/or come up with cash and wait on the system.   :cursing:   Universal care has its own problems, but care like this for no cost at the point of service is a huge blessing.

 

I won't say she's completely without fault.  Folks have been telling her for years that her spending habits need to change, she needs health insurance, and she needs an emergency fund, but all that doesn't mean my heart isn't going out to her right now.  She certainly didn't try to blow out her knee on the job, nor is it due to diet, smoking, or other lifestyle types of things.

 

Would her own health insurance even have made this better?  Or is she totally dependent upon workman's comp since it's a job injury.  (Just curious with this last bit.)

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Blew out her knee?  I don't know what that means, but if it is something that is not related to the work she was doing, when it happened, I don't think Workmans Comp will pay for it,    If it would have happened, for example, if she was at home or in the supermarket and is not directly related to her work, I think Workman's Comp will fight it.

 

I hope she is OK and I hope that she can get to another doctor, now, since the one she is scheduled for will be out of town for a week.

 

Good luck to her!

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She can ask if the workman Comp Dr will order the MRI because the ortho is out of town for two weeks. That's too late to wait, or another ortho approved by the workman Comp insurance.

 

She may be well aware she needs to save money, etc. NY is a very expensive place to live and may not be a great financial place to be able to do much, even if she wanted to.

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I don't know how it works in NY, but my work comp company assigns a case nurse that she could contact for medical needs. The case nurse is responsible for going between patient, Dr, employer and work comp company to get patient back to work as soon as possible. Most employers want you to get treated and back to work as soon as possible. If she is taken off work per Dr. Order, the work comp company should start paying her after a set amount of days, like 3 or 5. Going to therapy and all apps will be required. As an employer, the few times this happened we paid the other days do the employee was not out money.

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Blew out her knee?  I don't know what that means, but if it is something that is not related to the work she was doing, when it happened, I don't think Workmans Comp will pay for it,    If it would have happened, for example, if she was at home or in the supermarket and is not directly related to her work, I think Workman's Comp will fight it.

 

I hope she is OK and I hope that she can get to another doctor, now, since the one she is scheduled for will be out of town for a week.

 

Good luck to her!

 

I don't know how much this varies by state, but at least in Texas, if an injury happens at work, it is covered  by worker's comp--so if you trip and fall in the parking lot at work and break your leg, it is considered a worker's comp issue. 

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Your own insurance won’t cover anything if it’s a worker’s comp injury. The comp board denied further PT for my husband, but since the need for it was documented by the MD as an on the job injury, our private insurance won’t pay for it.

 

So it wouldn't have mattered if she had insurance.  That's at least good to know.  It has to be frustrating overall though.

 

is she waiting on approval for the mri, or waiting to get in to the doctor that would order it? ie is this the first visit since ER?

 

she can certainly pick another doctor. she can self pay anything the provider agrees to do.

 

private insurance doesn't matter in workmans comp case, but having an established relationship with a doctor is helpful, because they will likely take the case, patient doesn't have to wait long too be seen, and they know the patient history well enough to prescribe sufficient pain meds.  

 

if say, one wasnt sure if the case was workmans comp, and one began with private insurance, then one is in subrogation hades and has a lot of paperwork ahead of them.  same plus maybe losing job if one had the injury off worksite and then claimed it was done at work.

 

unfortunately lots of people can't agree with you politically. they just don't make enough money to be able to have large chunks given to govt, unable to use. and they know when their time comes, it won't be there. your sister may be in that group; the ones i know prefer to pay after the injury, $25/month rather than thousands in for decades with no payout due to some arbitrary loss in coverage  or eligibility rule.

 

eta: lanny has a very good point. the comp board will look at the task and the injury. she may need a lawyer who will do such things as show that she isn't using her knee in knee straining activities while not on the job and is able to get a higher percent of the injury costs paid for.

 

She's waiting on the Dr to order it, then Workman's Comp to approve it.  First she had to wait on Workman's Comp to approve the injury, but that's already happened.

 

She does not have an ongoing relationship with a doctor because like most folks uninsured, she doesn't go to doctors unless something is really needed.  Even then, when she's had needs, she finds she gets very little looked at or done because she can't pay for it and doesn't have insurance (and isn't literally dying requiring something get done).  So far though, those have mainly been digestive issues (possibly gall bladder).  She gave up trying on that a while ago.

 

I don't really want to get into politics and insurance.  I just know she wouldn't be having these problems in Canada - or Europe - or any real first world country.  It's frustrating.

 

She has contacted a Workman's Comp attorney, but not heard back from them yet.  I don't know how helpful they will be.  One of our tenants had a hand injury and went to court to get his settlement (mainly back wages) and won, but lost, because the attorney fees took most of the money.  He got very little in the end.

 

 

Blew out her knee?  I don't know what that means, but if it is something that is not related to the work she was doing, when it happened, I don't think Workmans Comp will pay for it,    If it would have happened, for example, if she was at home or in the supermarket and is not directly related to her work, I think Workman's Comp will fight it.

 

I hope she is OK and I hope that she can get to another doctor, now, since the one she is scheduled for will be out of town for a week.

 

Good luck to her!

 

It means she turned getting a package to deliver out of her truck and her knee collapsed under her.  She can't put weight on it any longer and it hurts considerably.  Medically, until they get the MRI done, I suppose they don't know.  X-rays only showed fluid on the knee.

 

Workman's Comp has approved the situation. 

 

She can ask if the workman Comp Dr will order the MRI because the ortho is out of town for two weeks. That's too late to wait, or another ortho approved by the workman Comp insurance.

 

She may be well aware she needs to save money, etc. NY is a very expensive place to live and may not be a great financial place to be able to do much, even if she wanted to.

 

She lives in a low COL area of NY, not the city. Her rent is $500/month and her salary is higher than 40K with no dependents.  She could do better with money.  Our whole family knows that.  It's been an issue forever with her.  She's older than I am, but financially, she can't grasp how to budget or save.  We've been at a loss with what to do.

 

We've been worried about things like this happening, so now will have to figure out what to do about it.  One would think things would be learned from the scenario, but other scenes have happened before and nothing sinks in.

 

I just need the correct nuts and bolts of "what's likely to happen" medically and financially so we can calculate it into our family discussions.  That's what I'm turning to the Hive for.  Experience on here is incredibly broad and deep.

 

 

I don't know how it works in NY, but my work comp company assigns a case nurse that she could contact for medical needs. The case nurse is responsible for going between patient, Dr, employer and work comp company to get patient back to work as soon as possible. Most employers want you to get treated and back to work as soon as possible. If she is taken off work per Dr. Order, the work comp company should start paying her after a set amount of days, like 3 or 5. Going to therapy and all apps will be required. As an employer, the few times this happened we paid the other days do the employee was not out money.

 

I wish her employer would do the same.  They're after her to return to work.  HOW?  She can't walk without pain and crutches, much less walk with packages.

 

She wants to get back to work as soon as possible too.  No work = no pay.

 

I'm assuming she was treated at a hospital?  Their social worker should be able to help her a bit.  I know I have the number of the social worker or WC liaison or whomever after DH's injury last year.  That's really all I know, but we had zero trouble with getting stuff paid.

 

She said she went to an Ortho Urgent Care, not an ER.  I'm not sure if that makes a difference.

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As far as the employer goes, they may have a light duty option for her. She should ask. However she will need a doctor’s note to tell them she needs light duty.

 

A hospital social worker won’t help guide her through the workman’s comp mess. They’re great for the uninsured and Medicaid, but workers comp will be handled by her company’s HR department and, possibly, an attorney.

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Very good news that's it's been approved. All medical expenses will be covered and she will be paid while she's off, although likely not for the first 3-4 days off and they're could be a lag. But they will back date it when it's approved. In our state you are paid about 2/3 of your salary, but it is not taxable for federal or state purposes, so it is close to being full pay.

Like any insurance company, you do have to be aggressive and advocate for yourself to keep your case moving. She can request another dr, or they can direct her to other providers who might be able to move up her testing and treatment.

If there are light duty positions, her employer will provide a job description with physical requirements and her dr will determine if she's able to perform those. Again, our workers comp provider would provide any difference in pay between the light duty position and her original pay if there is one.

She should be assigned a case number and a case manager to help her through the process. If she knows the employers' worker's comp provider, they'll have a website with a lot of information as well.

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I don't know how much this varies by state, but at least in Texas, if an injury happens at work, it is covered  by worker's comp--so if you trip and fall in the parking lot at work and break your leg, it is considered a worker's comp issue. 

 

That sounds good, if "blew out her knee" is an injury, due to an accident,  and not something that would have happened normally.

 

I hope she will be covered by Workmans Comp for this!

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Very good news that's it's been approved. All medical expenses will be covered and she will be paid while she's off, although likely not for the first 3-4 days off and they're could be a lag. But they will back date it when it's approved. In our state you are paid about 2/3 of your salary, but it is not taxable for federal or state purposes, so it is close to being full pay.

Like any insurance company, you do have to be aggressive and advocate for yourself to keep your case moving. She can request another dr, or they can direct her to other providers who might be able to move up her testing and treatment.

If there are light duty positions, her employer will provide a job description with physical requirements and her dr will determine if she's able to perform those. Again, our workers comp provider would provide any difference in pay between the light duty position and her original pay if there is one.

She should be assigned a case number and a case manager to help her through the process. If she knows the employers' worker's comp provider, they'll have a website with a lot of information as well.

 

Thanks.  I'm glad to read it's not taxed as yes, that should help make up the difference.

 

As of tonight she's heard nothing more from anyone - not the lawyer she contacted, not the doctor's office, not anyone from Workman's comp.  Nothing.

 

I asked if Fed Ex had any light duty job she could do to keep pay coming in and was told no.

 

I'll ask if she knows who her case manager is or the case number.

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Thanks. I'm glad to read it's not taxed as yes, that should help make up the difference.

 

As of tonight she's heard nothing more from anyone - not the lawyer she contacted, not the doctor's office, not anyone from Workman's comp. Nothing.

 

I asked if Fed Ex had any light duty job she could do to keep pay coming in and was told no.

 

I'll ask if she knows who her case manager is or the case number.

It isn’t taxed, but there is a limit on the 2/3 of your income. In NYS it is capped to something like $740 a week. So it’s 2/3 of your income up to $740. In your sisters case, she may not be making enough that the capped figure will come into play. We got hurt financially from it because it was 2/3 of my husband’s base pay, so we missed out on his usual overtime, plus we hit the cap.

 

Workers comp is a total pain. I hope it goes smoothly for her.

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Ok, she has the case manager's name and the case number, etc.  I misunderstood thinking the doctor was going on vacation.  It's not the doctor.  It's the Workman's Comp contact at the Orthopedic office.  Does that mean she's screwed for a week (medically) since they didn't get to her case before they left?

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I know very little about it and I already agree!

 

I'm wondering what happens medically if she has to wait a week just for the MRI. What if the body starts healing incorrectly - or is that possible...

Knee injuries tend to be ligament injuries, though there are others. Frequently they are allowed to heal on their own, sometimes they need surgery. So waiting may not be horribly horrible. :(

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Knee injuries tend to be ligament injuries, though there are others. Frequently they are allowed to heal on their own, sometimes they need surgery. So waiting may not be horribly horrible. :(

 

Yes.  In my corner of Canada, in the circumstances you describe (soft tissue injury to the knee:  Sprain vs strain vs ligament or meniscus injury) this patient wouldn't even be considered for an MRI this early.  Most of these injuries get better on their own and do not need surgery.  She would be advised to rest, elevate and follow up in 1-2 weeks for a clinical exam once pain and swelling have subsided.  If an MRI was thought necessary at that point, it would be ordered but would be non-emergent.  It would take weeks (or even months) to get it done.  If it was determined she had an ACL tear that needed surgery, it would be booked - electively. 

 

So a one week wait for an MRI seems completely reasonable from my point of view.

 

 

ETA:  She wouldn't likely see an ortho this early either.  She would be followed along by her family Dr.  If it is detemined that the knee is surgical, then an ortho opinion would be sought.  Not before trial of conservative management +/- imaging.

Edited by wathe
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Knee injuries tend to be ligament injuries, though there are others. Frequently they are allowed to heal on their own, sometimes they need surgery. So waiting may not be horribly horrible. :(

 

Thanks for that info.  I passed it on to her.  Hopefully it will help reduce her mental stress about it.

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Yes.  In my corner of Canada, in the circumstances you describe (soft tissue injury to the knee:  Sprain vs strain vs ligament or meniscus injury) this patient wouldn't even be considered for an MRI this early.  Most of these injuries get better on their own and do not need surgery.  She would be advised to rest, elevate and follow up in 1-2 weeks for a clinical exam once pain and swelling have subsided.  If an MRI was thought necessary at that point, it would be ordered but would be non-emergent.  It would take weeks (or even months) to get it done.  If it was determined she had an ACL tear that needed surgery, it would be booked - electively. 

 

So a one week wait for an MRI seems completely reasonable from my point of view.

 

 

ETA:  She wouldn't likely see an ortho this early either.  She would be followed along by her family Dr.  If it is detemined that the knee is surgical, then an ortho opinion would be sought.  Not before trial of conservative management +/- imaging.

 

Well, there's no family doctor in her situation so that's out and we have Ortho Urgent Care places all over, so that was her choice understandably.

 

But overall, she's feeling MUCH better medically knowing it's not an urgent situation, so once again I thank the Hive for sharing the knowledge they have!  I love the depth of knowledge accessible on here.

 

I'm pretty sure the intense pain, lack of ability to walk, and stress of knowing no work = no pay, so no bills paid built up a ton of stress.  It's nice to know the medical part is going along ok.  As a family, we'll see what we can do with the financial part.

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While not the knee, I had a grade three sprain in my ankle in August 2016. Severe ligament tear. It was June of 17 before they did an MRI and I’ve done physical therapy for months. It’s only now that they’re doing surgery. She’s only going to be told to ice and rest and elevate at this point. There’s no harm in waiting a while for an MRI.

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My husband HATES workman's comp and is one of the few docs to actually take it.  There is SO much paperwork and red tape.  Ok, she needs to talk to the doctor's office and ask about what the delay in the MRI would mean.  I could mean nothing or it could make a difference depending on the injury.  If it is going to make a substantial difference, then she needs to talk to the doctor's office and get them to push to get approval from whoever her replacement is.  My husband's office has a lady who does nothing but work with all of the red tape with workman's comp, Medicare, etc.  

 

Oh, I just reread it, it is that lady.....  Great.  Ok, she needs to call the doctor's office and ask how this will impair her recovery and how she can get it sped up if that is the case.  She may very well be up a creek....

 

Any chance your husband agrees that it's normal to wait a week for swelling to subside, etc?  It'd be nice if there were agreement.

 

My medical knowledge is quite limited.

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I don't know how much this varies by state, but at least in Texas, if an injury happens at work, it is covered  by worker's comp--so if you trip and fall in the parking lot at work and break your leg, it is considered a worker's comp issue. 

 

If they sent you to the parking lot to collect buggies, yes. If you went out for a smoke, no. It has to be work related, and the worker needs to be following the rules. Unless Texas is odd, which is certainly possible  :D

 

She has contacted a Workman's Comp attorney, but not heard back from them yet.   

 

 

That's really jumping the gun, imo. It's bureaucracy, it takes time, and a lawyer isn't going to make this early process move any faster. And definitely won't endear her to her employers, lol. I don't think there are any states that require compensation that quickly - partially because the doctor needs to give a preliminary estimate on how long they will be out. 

 

I'm pretty surprised that Fed Ex does not insure their workers! 

 

Ok, she has the case manager's name and the case number, etc.  I misunderstood thinking the doctor was going on vacation.  It's not the doctor.  It's the Workman's Comp contact at the Orthopedic office.  Does that mean she's screwed for a week (medically) since they didn't get to her case before they left?

 

No, there should be procedures in place for that, or they will assign her to a different doctor. They won't just have her going a week plus with no medical attention unless they are incredibly stupid. 

 

As far as work pressuring her to return, I wonder if she is misreading that? Once a workman's comp case is opened, they can NOT have her return until it's signed off on by workman's comp (generally, if not always, a separate company) and the doctor. They can have her on  desk duty or such, but that will be specified in the sign-off, and then they will have to sign off again when she goes back to regular duty. 

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That's really jumping the gun, imo. It's bureaucracy, it takes time, and a lawyer isn't going to make this early process move any faster. And definitely won't endear her to her employers, lol. I don't think there are any states that require compensation that quickly - partially because the doctor needs to give a preliminary estimate on how long they will be out. 

 

I'm pretty surprised that Fed Ex does not insure their workers! 

 

 

No, there should be procedures in place for that, or they will assign her to a different doctor. They won't just have her going a week plus with no medical attention unless they are incredibly stupid. 

 

As far as work pressuring her to return, I wonder if she is misreading that? Once a workman's comp case is opened, they can NOT have her return until it's signed off on by workman's comp (generally, if not always, a separate company) and the doctor. They can have her on  desk duty or such, but that will be specified in the sign-off, and then they will have to sign off again when she goes back to regular duty. 

 

With the lawyer part, it doesn't surprise me.  Both she and my dad are quick to jump to lawyers for pretty much anything.  It could be why the lawyer hasn't contacted her back yet though.  My dad has the same "problem" with lawyers.  ;)

 

From what I understand with Fed Ex, their deliveries are franchised out to individual owners so there's quite a bit of variance in what you get for workers.  She could buy into their health insurance, but she says she doesn't have enough money.  Knowing what she spends her paycheck on instead (many things most of us would not consider needs), she doesn't have it.  She refuses to change her spending priorities.  That seems to not be an issue in this case though.

 

Her employers aren't very business savvy (and have received fines for it in the past - failure to pay various things).  They probably don't know (or care) that her return needs to be signed off on.  They only know they have a huge number of packages not being delivered at the moment and with Christmas coming, they're entering peak season.  They're usually hurting for drivers and those they have get quite a bit of work. It's not easy replacing a driver.  They keep some on that they shouldn't (for various reasons), but they need them.  If she could find a better job, she would, but she's been through several jobs (personality) and this is where she's at.

 

It's not a great situation all around, but she's my sister and this injury is real, so I want to glean some knowledge to know how to advise and help.

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If they sent you to the parking lot to collect buggies, yes. If you went out for a smoke, no. It has to be work related, and the worker needs to be following the rules. Unless Texas is odd, which is certainly possible  :D

 

 

Yes, a family member in Texas was leaving work and fell in the parking lot and broke a leg--it was an employer owned parking lot (the family member preferred not to have it considered workers comp but health insurance would not cover the injury)

 

Apparently this can be the case in other states also.  Her are some examples in Illinois http://www.illinoisworkerscomplaw.com/2014/06/the-tricky-thing-about-parking-lot-injuries-at-work/ and Missouri http://www.roskinhoffmann.com/blog/entry/workers-compensation-and-parking-lot-injuries.html

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She's in NY.

 

Yikes... sounds like there's going to be a major financial need soon for her to be able to keep paying bills. The main problem with that is she never pays anyone back when they loan her money, so it's a larger decision than the obvious.

 

She mentioned having to get a lot of paperwork submitted today - all while in pain and not being able to really walk.

 

I still wonder with her assigned dr going on vacation if anything will even get done within the next week.

She needs to apply for emergency welfare benefits from the state.

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Any chance your husband agrees that it's normal to wait a week for swelling to subside, etc? It'd be nice if there were agreement.

 

My medical knowledge is quite limited.

My ortho PA considered a second MRI after a new sprain last week, but decided against it due to how swollen everything is. She seemed to think they’d have better imaging if it wasn’t so swollen.

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She needs to apply for emergency welfare benefits from the state.

 

I am glad this is there (assuming it is), but TBH, our family tends to pull together to help each other out in financial emergencies so we will do this again after letting her see what she can do in person and perhaps getting a little realization of why the rest of us find it necessary to have an emergency fund.  It may be enabling, but such is life.  It's what we do for each other.  If folks disagree, take consolation that no tax dollars are being spent.  ;)

 

My ortho PA considered a second MRI after a new sprain last week, but decided against it due to how swollen everything is. She seemed to think they’d have better imaging if it wasn’t so swollen.

 

Thanks.  She went back to the ortho place again this morning and they said they want to see her on Monday.  I suspect from what y'all are telling me, that they're doing their job on the medical end just fine, other than maybe not explaining enough.  I've texted her exactly what some of you have said about knee injuries and that's helped her mentally quite a bit about that part, so y'all definitely have my thanks for sharing your knowledge and experience.

 

She's still in pain, etc, from this, but said she can put a little bit of weight on it, so I think it's getting better.

 

Her main concern is the finances.  Supposedly, her Fed Ex place (she works Fed Ex Ground) is resisting giving her her paycheck today.  She's there now.  I'm waiting to see how it turns out because that one really doesn't make sense.  This is for work she did, not expecting pay for when she had to stop.  If her workplace is as she describes it, they need to go to their local CC and take some Business classes.  I know I'm only getting one side of the story, but the fact that they've been fined before leads me to believe her side - at least to a point.

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Just updating that she was able to get her paycheck, so all seems well there.  She says there's no longer any problem with work letting her be off until the dr clears her to work again.  Hopefully this ends the "problem" of it all and healing goes well.  Thanks for the info everyone!

 

 

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