A year after being shot in a terrorist attack, employees of San Bernardino County, Calif., are struggling with delayed or denied workers’ compensation claims.
A year after a terrorist’s bullets ripped through her, after so many operations and infections she has lost count, Valerie Kallis-Weber has a paralyzed left hand, painful bone and bullet fragments in her pelvis, psychological trauma and tissue damage, including a fist-size gouge in her thigh where a bullet tore away the muscle.
Kallis-Weber, a survivor of the Dec. 2, 2015, shooting in San Bernardino, Calif., that left 14 people dead and 22 seriously injured, still faces a long, hard road to reach something like recovery. She needs more operations, she relies on a home health aide, and her doctors want her to get physical and occupational therapy to relearn to use her arms and legs.
“I can’t type, I can’t put a bra on, I can’t cut a steak, I can’t drive, I can’t do laundry, I can’t wrap a present, I can’t put my shoes and socks on, I can’t do much walking or standing or sitting,” she said. “I need help with everything.”
But the visits from the health aide have been reduced, and she has been told they will end soon. Approval of her antidepressant medication was withdrawn. Her occupational therapy was cut off, and her physical therapy stopped, restarted and stopped again.
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Her conflicts over treatment are not with her health-insurance plan; the shooting was a workplace attack, not covered by regular insurance.
Instead, her treatment comes under the workers’ compensation system, which in California and many other states often restricts coverage more than does health insurance.
Kallis-Weber and other victims of the attack, all San Bernardino County employees, have spent months fighting the county and private companies that help administer the system, as treatments that their doctors approved have been delayed or denied.
“I was shot by terrorists, and it feels like the people I worked with are victimizing me all over again,” said Kallis-Weber, 59, who spent three months in a hospital and a rehabilitation center after the shooting.
The county and the victims disagree about what the county should — or even could, legally — do for the survivors. The employees say the county could simply pay for medical care, even if it is not strictly required by California law; county officials have insisted that an employer has no role in making such decisions.
Officials with the California Department of Industrial Relations, which oversees workers’ compensation, told county officials Monday that they could, in fact, provide care beyond what the law required, said Christine Baker, the department director.
A county spokesman, David Wert, conceded that treatment approval had been balky, but he said the county did not want to deny anyone needed care.
“We’re very frustrated at the system, and by the fact that our employees are not happy with what’s going on,” Wert said.
County workers check in regularly with survivors, trying to resolve their problems, he said, adding: “We’re actually in the process of hiring a dedicated workers’ comp liaison to work solely with these people.”
Both sides say that part of the problem lies with the state workers’ compensation law and the guidelines for applying it, which anticipate common workplace injuries like those resulting from a slip and fall, not those seen in a war zone. The guidelines say treatment cannot be denied just because a condition is not explicitly mentioned, but in such cases, decisions become less straightforward.
California and several other states have also changed their workers’ compensation laws in recent years, in ways that curb benefits and save employers money. A 2013 change in California removed the option of appealing a denial of coverage to a state administrative-law judge. This makes the process faster but also means that denials are reversed much less often.
“The guidelines in the law are one-size-fits-all, which doesn’t work for unusual cases, and we used to have the ability to convince a judge of that,” said Marc Marcus, a workers’ compensation lawyer in Sacramento who is not connected to the case.
As in other mass attacks, charitable groups have raised millions of dollars to help the victims in San Bernardino, and some medical providers have given their services free.
But survivors of the other attacks have usually not had to deal with workers’ compensation.
As employees of the San Bernardino County Department of Public Health took part in training sessions last December, one of them left and then returned with his wife. The couple carried out the slaughter using variants of the AR-15 assault rifle. The weapon’s bullets travel three times the speed of rounds from a typical handgun and often fragment, causing wounds that trauma surgeons say are far worse than those from ordinary gunshots.
One bullet hit Amanda Gaspard, now 32, in the right leg, fractured her thighbone, destroyed muscle tissue, tore away part of her knee cartilage and damaged the top of her shinbone.
Another bullet hit her right forearm, and flying debris peppered her body.
Half of her blood drained onto the conference- room floor.
She could not put any weight on her leg for three months, and it was not until August that she could stand long enough to take a shower. Her orthopedic doctors say her leg needs reconstructive surgery, including a bone graft, but it is not clear whether workers’ compensation would pay for the specialized operation.
For now, she can walk, with a cane, for only a short time — or not at all, depending on her level of pain.
“I have literally hundreds of pieces of shrapnel in me,” Gaspard said. “The word ‘painful’ doesn’t do it justice.”
She goes to physical therapy weekly, but workers’ compensation is not paying for that, and her doctors’ requests for therapeutic exercise sessions with a trainer have been denied.
California workers’ compensation guidelines place limits on how much physical therapy an employer must provide if the patient is not improving. Therapy can be denied, even if the patient would deteriorate without it.
In California and many other states, a request for services under workers’ compensation goes to a private firm, hired by the employer, for “utilization review.” That company has a doctor review the case file and decides whether services are medically necessary and legally required. Its decisions can be appealed to another company, hired by the state, for a second review.
For months, county officials have said they are required to abide by the decisions; it was not clear whether that would change after the state’s intervention Monday.
Shooting survivors and workers’ compensation lawyers have insisted that if patients’ doctors call for treatments that are considered appropriate, the county’s Department of Risk Management, which processes claims, is free to approve them, even if they are denied in utilization review.
Excel Managed Care, the utilization review contractor the county used for many of the San Bernardino claims, agreed.
Lawyers and victims also question whether the doctors reviewing case files — who never see the patients — have experience with injuries like those in the San Bernardino shooting.
Excel, which no longer works for the county, “at all times matches the specialty of the expert reviewer to that of the requesting/treating physician as closely as possible,” Brenda Smith, the chief executive, wrote in a statement in response to questions.
“This would apply to wounds, trauma and other injuries which might be sustained in a terrorist attack,” she said.