There is an investigative reporter for a national news outlet who is writing on the subject of workers compensation claims being approved on denied based on guidelines established by medical associations – and if conflicts of interest by policy-writers unduly influence the denials.
If you can prove that your claim of needed insurer compensation for injury from toxic mold was denied based on one of the following three medical association position statements; your case may be newsworthy and possibly subject to review.
1. American College of Occupational and Environmental Medicine (ACOEM) Adverse Human Health Effects Associated with Molds in the Indoor Environment by Bruce Kelman & Brian Hardin of Veritox, Inc; and Andrew Saxon of University of California Los Angeles.
2. American Academy of Allergy, Asthma and Immunology (AAAAI) “The medical effects of mold exposure” by Andrew Saxon of UCLA, Robert K. Bush of the University of Wisconsin, Abba I. Terr of the University of California San Francisco and Robert A. Wood of Johns Hopkin University. Forged stated authorship of Jay Portnoy of the University of Missouri (See link to WSJ article below)
3. American College of Medical Toxicology (ACMT) “Institute of Medicine Report on Damp Indoor Spaces and Health” by Danile Sudakin of Veritox, Inc. and Tom Kurt, Medical Review Officer for the State of Texas.
WorkCompCentral recently published an article titled, “ACOEM Takes Down Position Paper commonly Used to Defend against Mold Claims“. It is regarding ACOEM, which is an occupational physician “non-profit” trade organization. They write medico-legal guidelines which determine the care -or lack there of – for injured workers throughout the United States.
The gist of the article is of ACOEM sunsetting their position statement on injuries caused by mold. The term “sunset” means to retire a policy paper and no longer promote its findings as the organization’s current scientific understanding of illness, injury and causation. The article states,
“Dr. Ritchie Shoemaker, a mold researcher who has testified in more than 200 court cases related to mold illness, said the ACOEM paper was ubiquitous in litigation for many years. ‘After 2003, there were no cases that I participated in where defense did not quote ACOEM,’ he said.”
ProPublica recently published an expose’ titled, “The Demolition of Workers Comp“. According to the article, California workmans’ compensation insurers are retroactively denying prior approved claims and treatments based on new law. This new law allows decisions to be made by annonymous Medical Review Officers (MRO). The article states,
“Joel Ramirez, a 48-year-old paraplegic in California, never even got to see the doctor who took away his medical care. Last June — without examining Ramirez or even sending someone to assess his daily struggles — his former employer’s insurance company terminated the home health aide he relied on.
Such cases underscore the consequences as states seek to streamline disputes and take more control of medical costs. But along the way, such provisions have tilted systems in favor of employers and stripped away fundamental protections that guaranteed workers the right to be examined by doctors and heard by judges.
A 2012 California law, supported by both business and labor, was intended to solve problems with an earlier reform that had left workers waiting months to see impartial doctors and months more for administrative hearings.
Under the new process, disputes are decided by independent medical reviewers [MRO] chosen by a state contractor. These doctors, many of whom are licensed out of state, rely solely on medical records and remain anonymous. Their decisions can’t be overturned except in limited cases.
Lawmakers also added a surprising twist: The medical dispute process wouldn’t just apply to new cases, but retroactively. Suddenly every treatment request in the system — whether it be for surgery or a simple prescription refill — could now be subject to reviews by insurance company doctors and compared against more rigid medical treatment guidelines that might not have been in place when care was approved.
And reviewers routinely rule against injured workers’ doctors, denying treatment in 91 percent of disputes, according to preliminary data to be released this month by the California Workers’ Compensation Institute, an insurance research group….But in some instances, records and interviews show, injured workers have been denied treatment simply because the reviewer didn’t have the right medical records.”
ACOEM writes treatment guidelines for injured workers that insurers and MRO’s rely upon to approve or deny claims. AAAAI’s mold statement (that was sunset in 2011) and ACMT’s are both based on ACOEM’s mold statement, which was sunset in 2015. They are no longer viable weapons to be used in insurer/MRO denial of claims made by those who have been injured by toxic mold.
It stands to reason that if prior approvals can be subject to retroactive denial based on policy changes; so should prior denials be subject to retroactive approval based on policy changes.
If you have a clear cut case of the ACOEM, AAAAI or ACMT Mold Position Statements being used in the denial or delay of compensation and treatment for injury from mold and other biocontaminants in water damaged buildings, please send an email to me with the corroborating documentation.
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