How Do TTD Payments Work For a Denied Claim That's Now Been Approved?
So back in January when I got hurt, I went to sent to urgent care. The urgent care doctor said they couldn't properly treat me and I needed to see an orthopedic surgeon. I took the referral and gave it to HR who forwarded it to Sedgwick. Sedgwick opened a claim for me, and then made me wait 6ish weeks for the prior authorization. During that time I was sent BACK to the Urgent Care to get a note keeping me out of work, and also for a referral for PT.
After the 6ish weeks (this is March now) Sedgwick tells me that they're not approving the referral to see an orthopedic surgeon. They said I need to go see their doctor at Concentra. So I get annoyed and hired a lawyer. My lawyer tells me to go to Concentra for now while they work on getting my claim before a judge so I can see the Surgeon. Well the doctors at Concentra tell me I'm exaggerating my injury and pain. They tell me it's just mild soft tissue damage and write a note to send me back to work. The doctor then schedules a follow up visit for the following week, because he wants me to start physical therapy.
A LOT HAPPENS DURING THIS WEEK:
I give the note with the restrictions back to HR who then forwards it to the claims adjuster at Sedgwick. The note states that I can't work for more than 3 hours a day. However HR and Sedgwick both interpreted that to mean I can't use my right arm for more than 3 hours a day. They suggested I switch to my left hand for the remaining 5 hours of my shift. I told them that's not what the note says . So HR tells me to go back to Concentra and have it written it exactly how they want it then. I also tell my lawyer this as well.
For context I broke my right shoulder (but we didn't know this at this time because I didn't have an X-Ray or MRI done and Concentra refused to do any imaging. You might be asking yourself, but what about the Urgent Care I went to? Well, they couldn't do any x-rays that day, and they also didn't handle my injury type, which is why I was being referred to the Surgeon.
So the following week during my follow up, I asked for my specific restrictions, and I gave the new note to both my lawyer and HR. HR then called me and said they can't honor this note. They said that they don't offer 3 hour shifts. And because my claim wasn't approved or denied, it was up to their discretion on whether or not they would honor it. So I called my lawyer and she had a conference call with Sedgwick and HR about this. My lawyer calls me back later and said unfortunately what they told me was correct. And to add insult to injury, they added an ultimatum, either accept their interpretation or be forced to quit.
Then the literal next day, I received a call from Concentra telling me my PT Appointment had been cancelled because my claim was now denied. So I called my lawyer, who said they just received the email also saying my claim was now denied. Sedgwick decided that based on the reports from the 2 doctors visits from Concentra, there was no need to approve my claim. I was "exaggerating" the severity. As a result I was forced to resign because HR was now refusing to accept any work status note, and I literally couldn't work.
Well fast forward to now (June 29th), and my claim is approved. My lawyer convinced Sedgwick and the Judge to let me see a Surgeon and get an MRI and an X-Ray. The images confirmed that I broke my AC Joint, tore my Supraspinatus, Fractured my Humerus, and dislocated my shoulder when I got hurt. But according to Concentra I was "exaggerating" everything.
So here's my question:
How does TTD and Backpay work for a claim that was originally pending, with approved time off, that turned into a denial for everything, that turned back into an approval? And during the denial you were forced to resign, but now with the approval status, you're being kept out of work until you complete 32-48 visits of physical therapy then do AC Joint and Ligament Repair Surgery in January 2026?
My lawyer is also pushing for undue delay fees and interest, and has been told there's a very strong chance the Workers Comp Commissioner will approve this, because of how horribly my claim was treated and I have the scans to prove the severity of my injuries.
Posted Jun 30, 2025, 3:14 AM UTC