COLUMN ONE : Forgotten Victims of Job Injury : As state lawmakers focus on abuses in the costly workers’ compensation system, employees who really need help find that the road to benefits can be filled with roadblocks.

Nearly broke and terminally ill with cancer, Jim Deaton filed a workers’ compensation claim in November, 1984, to cover his mounting medical bills and leave some cash behind for his three children.

The claim, several doctors concluded, was legitimate: For 13 years, Deaton worked in Salinas at the former Firestone tire plant, where he mixed solvents known to cause the type of stomach or pancreatic cancer he developed.

But Deaton died at age 43, eight months after filing his claim, without ever receiving a penny from California’s $12-billion workers’ compensation system. Six years passed before his children received their dependents’ benefits, in a settlement totaling $60,000.

During the years the case was fought, the lawyers for Firestone’s three workers’ compensation insurers won delay after delay, “trying to get us to give up,” said Deborah Deaton Cagle, now 30 and Deaton’s eldest child. “But I was representing my dad, and I wasn’t going to let them do that.”

The Deaton family and others like them are the largely forgotten victims of California’s trouble-plagued system for compensating injured workers. Gov. Pete Wilson and state lawmakers, whose efforts to pass workers’ compensation reforms collapsed Friday in a special legislative session, have focused mainly on abuses that keep driving up costs for employers.

Meanwhile, many injured employees and their families--the people the workers’ compensation system is supposed to help--find that extracting workers’ compensation benefits from insurance companies and employers in California is a maddening ordeal. All too often, they are forced to endure excruciating delays and seemingly endless humiliation in getting medical care, money and vocational rehabilitation they are due from workers’ compensation--if they ever get the aid at all.

Friction between insurance carriers and people filing claims is not unusual, but in workers’ compensation disputes, the stakes are high. Many people hurt on the job have no other coverage because of the growing number of firms that no longer provide employees with health insurance.

Some delays in delivering benefits to needy workers were relieved by legislative reforms in 1989 that brought about expedited hearings in some disputes and added more judges to the system. But “a significant minority” of insurers and employers still “inappropriately, and in some cases, maliciously deny claims and deny payment,” said Burt Margolin, the Los Angeles Democrat who chairs the Assembly’s insurance committee.

The widespread worker dissatisfaction with California’s program is reflected in the vast number of cases that wind up in the hands of lawyers--an anomaly in a system designed to be no-fault. When employees in California lose more than three days of work because of injury, they hire lawyers an estimated 41% of the time to handle their claims.

“Most of these people don’t even want to go to lawyers. They feel guilty about it. But they do it after they’ve been pushed,” said Richard I. Felton, a Los Angeles attorney who represents injured workers.

Insurers and employers say they are not trying to keep injured workers from getting help. Rather, they say, they are trying to curb the deluge of abuses they encounter by challenging workers’ compensation claims that appear to be excessive or fraudulent.

But in the process, they concede, innocent people get hurt. “When you glut the system with a lot of cases that don’t have merit, it delays payments to people who are really hurt,” said Steven Snyder, a vice president of claims for Fremont Compensation Insurance in Glendale.

Many critics of insurers and allied employers are less charitable, accusing them of bullying workers and their doctors to head off legitimate complaints as well as bogus ones.

“Anyone who goes against the insurance companies’ wishes is labeled as a fraud, a criminal or negligent,” said a psychiatrist who asked not to be identified for fear of being cut off by insurers.

Many workers’ compensation patients, the psychiatrist said, “are people who have worked all their lives. Why should they be called fraudulent criminals just like that?”

Hardship strikes injured workers in many ways. In some cases, disabled workers win workers’ compensation benefits only to have them cut off later for no apparent reason.

Consider Millie Sargisoff. She was forced to retire from the Thrifty drugstore chain in 1980 because of two back injuries she suffered during her 23 years there as a retail clerk.

In the years since, Sargisoff, 64, has managed to scrape by. She shares her Pasadena apartment with her 87-year-old mother and covers the bills with their Social Security checks and her $274-a-month pension from Thrifty.

But recently, a key part of Sargisoff’s economic safety net unraveled--the lifetime medical benefits she was awarded from Thrifty by a workers’ compensation judge 10 years ago. The insurance company now handling Sargisoff’s case has refused to pay the roughly $10,000 in hospital and doctors’ bills she ran up last year when her crippling back pain flared up again.

Felton, her lawyer, calls it a typical example of how insurance companies and self-insured employers fight injured workers even after employees win their cases in court. Using workers’ compensation medical benefits, he said, is often “a miserable experience” because insurers can freely raise objections about how the money is spent with little fear of penalty.

The company Sargisoff is up against is a unit of American International Group, a New York-based international insurance and financial services giant. American International took over the Sargisoff case years ago as part of a deal in which it bought all of Thrifty’s pre-1983 workers’ compensation liabilities.

Chris Bement, a Thrifty vice president, said he is sorry to hear about Sargisoff’s problems but that the case is “out of our hands.” American International officials declined to return several phone calls seeking comment.

Insurers can legitimately refuse to pay medical bills for workers granted permanent medical benefits in some instances--if, for example, the employee gets treatment for a shoulder injury when the award issued in the workers’ compensation case was for a neck problem. But that is not the type of challenge being raised against Sargisoff.

Instead, Felton said, the insurance company argues that Sargisoff’s recent hospitalization stemmed largely from arthritis in her back and not from the back injuries she suffered while lifting heavy boxes at Thrifty. The trouble with that argument, Felton says, is that Thrifty took the same position and lost 10 years ago when it fought Sargisoff’s workers’ compensation claim in court.

The insurer’s real aim, Felton says, is to get Sargisoff to waive her medical benefits in exchange for a lump sum payment. She refused a similar buyout offer made a couple years ago, preferring the security of lifetime medical coverage. “They’ll make her life miserable until she does settle,” Felton said.

“They’re an insurance company,” he said. “How does an insurance company make money? By denying people benefits. That’s the crux of it. . . . They’re doing everything they can to save money.”

Meanwhile, Sargisoff is left with the threat of bills she cannot pay hanging over her head, and she does not know what she will do if she needs back treatment again.

“Why would they do this to me?” Sargisoff said. “I’m not looking for something for free. . . . I worked hard for 23 years for that company. I don’t think I should be shoved aside like that.”

The often adversarial nature of workers’ compensation medicine prolongs the aggravation of many injured workers by delaying or thwarting proper treatment. In some cases, workers are sent to “company doctors” who ignore or downplay their ailments to get workers’ compensation insurers and employers off the hook for expenses. In turn, workers often go to doctors known to slant their evaluations in favor of the patients in workers’ compensation disputes.

Even when the circumstances are not blatant, the mutual suspicions between employees and company doctors often turn the doctor’s office into a battle zone. Just ask preschool teacher Rosa Rivas.

Rivas says that an insurance company orthopedist started yelling during her evaluation, called her a fraud who was lying about her on-the-job injuries and said, “All you Hispanics are alike.”

The orthopedist denies the charges, and instead says that Rivas “got very angry” after he told her that “we didn’t find much wrong with her.”

Despite evidence that Rivas is no fraud, the insurer--Cypress Insurance of San Mateo--has balked at providing some medical care she wants.

Rivas, 37, says she has lived with crippling pain for 15 months--ever since she fell hard in the school kitchen while rushing to answer a telephone--and she wants Cypress to pay for surgery on her aching shoulder. Her doctors say she is injured. Even the other health care specialist hired by Cypress to evaluate Rivas, chiropractor Gerald L. Pearlman, agrees that she is hurt and may need surgery.

Cypress declines to comment. But it ignored Pearlman’s advice and Rivas’ wishes to retain a new orthopedist to clarify whether she needs surgery, and instead is standing by the position of the orthopedist with whom Rivas clashed.

That doctor, Vincent C. Kent of Long Beach, devotes about 20% of his practice to insurance company evaluations of patients with workers’ compensation claims. He says that half of those patients either fake or exaggerate injuries to collect benefits illicitly, posing an undue burden on business.

As for Rivas, Kent says she was uncooperative and refused instructions to help him evaluate her. “She refused to allow us to do anything,” Kent said. “In light of her incomplete exam, there was no justification for surgery.”

Further, Kent said in a medical report that observations of her movements around the office before and after her exam demonstrated “essentially normal range of motion.”

Why was Rivas uncooperative? Rivas said she was in too much pain and told the doctor so. The doctor-patient rapport needed for a good evaluation also may have been undermined by her distrust; Rivas said she went into her exam uneasy about the insurance company doctor’s motives.

While many bogus complaints are filed by laid-off workers and others with grievances against employers, Rivas is an employee in good standing at Pasadena’s Pacific Oaks Children’s School and College. Aside from taking off three months this summer, Rivas has been working at the school four years.

Rivas says she is not financially needy and would not file a phony claim. She earns about $17,000 a year, her husband of 18 years is an RTD bus driver and they draw additional income from a duplex they rent out.

“I have a comfortable life,” said Rivas, who moved to Los Angeles from her native El Salvador at the age of 5. “We have our home. We have two cars. We have a boat, which is enough for me.”

Rivas said all she wants is for Cypress “to take responsibility” for the treatment she needs.

Rivas says she is furious that Cypress appears to be putting her in the same category as workers’ compensation cheats, and that is why she wants to fight the company. “I’m paying the price for everybody’s fraud,” she said.

Many injured workers say another major problem is insurance company lawyers who try to wear them down by intentionally dragging out cases for years. Even though the Deaton case was more complicated than most, the legal wrangling that prevented the late Firestone employee’s family from receiving its benefits for so long is commonplace.

Among other things, lawyers for Firestone’s insurance companies long argued that Deaton’s cancer might have stemmed from another source, perhaps from his work as an auto upholsterer. After the Firestone plant closed in 1980--costing Deaton his job and health insurance--he turned to upholstery work for a living.

Yet doctors retained by both sides in the dispute found that Deaton’s cancer was linked to his job at Firestone. The insurance companies never came up with an expert medical opinion that contended otherwise.

Later, the case was stalled by bickering among Firestone’s three workers’ compensation insurers over how much each company owed, said Amanda Hawes, the family’s lawyer.

Perhaps most annoying was when the case was delayed at a critical point for six weeks when a key insurance company lawyer took a long bicycle trip.

“It was just one more rationale for not getting things done,” Hawes said. “They put you through so much for something you’re entitled to.”

The delays were especially frustrating given the relatively modest amount of money awarded under the workers’ compensation system. Even under the higher current limits, the most that dependents usually can receive from death benefits is $115,000. And rarely can injured workers win damages in civil court, even when the employer is guilty of negligence.

For her part, Cagle, Deaton’s eldest daughter, was left with bad feelings toward the insurance companies and their lawyers.

“They have to have a little more feeling for the people who go through this,” she said. “This is why it (workers’ compensation) is there, in case something like this happens.”