Part 1: Overview of Workers Comp Claims…
The workers compensation laws of today are a patchwork of various state laws and regulations. The workers compensation system as a whole has been called “archaic” and “overly complex.” It’s tough to argue with that assessment.
This article reviews some basic tenets of workers comp and gives an overview of claims procedures. It’s impossible to address each state’s laws and regulations here. Therefore you should become thoroughly acquainted with your specific state’s Workers Comp laws.
How to Comply with Workers Compensation Laws…
If you were employed by a company which provided workmans compensation insurance and you were injured on the job, there are some steps you should take immediately or as soon as reasonably possible. Doing so will preserve your legal rights to lost wages, medical attention, and in some cases, future pain and suffering.
If you are injured while performing your job duties, notify management immediately. The sooner you notify them the better it will be for you in the long run. If you are seriously injured and the sheer nature of the injury requires immediate medical attention you can forego notifying management until your injury is stabilized.
Once stabilized, notify management or the proper administrator in the Human Resources Division. Your employer should have a formal claim form for you to complete. If your injuries prohibit you from completing the claim form then have someone you trust complete the form for you. Make sure the person completing the claim form, whether you, a trusted friend or fellow worker, does so accurately and without embellishment. Also be sure you keep a copy of the form.
Continue your medical treatment until such time as the physician clears you to return to work. The physician will likely be recommended by your employer or your employer’s insurance company.
Shortly after your claim form has been submitted you will receive a telephone call from a representative from your employer’s insurance company, known as a “Claims Adjuster”. She will take a recorded statement from you. Be sure to tell the truth and be as accurate as possible. Do not embellish your rendition of the facts and circumstances which led to your injury. Remember, these claims adjusters have heard so many claims they can usually spot any inaccuracies or embellishments.
The adjuster will do a variety of things. After receiving and reviewing the medical information (referred to as the “Diagnosis” and “Prognosis” of your specific injuries), she may clear you for future medical treatment. The Diagnosis and Prognosis comes in the form of a medical narrative from the treating physician.
The Diagnosis is a statement from the physician indicating the type of injury you sustained and the possible cause of the injury.
The Prognosis refers to the future effect the injury will have. Included will be the physician’s review of the facts causing the injury, and her opinion of the future effects of the injury.
The physician’s narrative may indicate the need for future medical treatment, the progression of the injury, and an estimate of the amount of time before you’ll be able to return to work. With that information in hand the adjuster will determine the amount of money she’ll authorize for your continuing medical treatment and lost wages, if any, while you are at home or in the hospital recovering.
If you disagree with the adjuster’s decision you can request an Administrative Hearing before the Worker’s Compensation Board. Requesting an Administrative Hearing takes the decision out of the adjuster’s hands and places it in the hands of an Administrative Judge.
Your next step should be to ask your Human Resources case worker or the claims adjuster for a copy of the contents of your file. The contents should include every document of any type someone placed in your file, including but not limited to:
- Physician’s medical narrative (Diagnosis and Prognosis)
- Medical chart notes, opinions & memos
- Test results, X-rays, and any other medical procedure records
- Any photographs and recordings
- The original claim form
If for any reason you feel a document was omitted you can send a letter, Certified Return Receipt Requested, to the adjuster demanding a copy of the omitted documents(s).
If the Judge denies your worker’s compensation claim, or if the Judge hands down a decision which orders disability payments in an amount you disagree with, you can file an appeal of the Judge’s decision. In the file you created earlier place a copy of the Judge’s Order denying your claim. The Order will usually contain the facts the Judge based her decision on.
There is a time limit within which you may file an appeal of a workers compensation decision. States vary on the time limits so it’s always smart to check with your employee representative. In any event you should file as soon as possible. If you miss the deadline you may lose your right to recover any amount of compensation and may be left to pay the outstanding medical bills yourself.
Appeals and Workers Compensation Laws…
Let’s say you were injured on the job and make all the proper notifications but your workers comp claim is denied. You find out you might have to pay the emergency room and hospital bills yourself! Don’t throw in your chips yet, you do have the opportunity to appeal. The appellate process can be lengthy and require a working knowledge of legal proceedings, so you should consult an attorney .
To file an appeal go to your employer or the claims adjuster and ask for the form to file an appeal. Usually the process begins by filing an appeal directly with the insurer who denied your initial workers comp claim.
If filing all internal appeals is not successful, then you’d file with the administrative agency in your state that’s vested with handling workers comp denials. This agency may be called the Division of Workers Compensation or Workers Compensation Board. Usually you’ll be asked to undergo mediation once you file the appeal. If mediation fails, you may go before an administrative law judge who will decide the claim for you.
If you’re still not satisfied you may be able to appeal to the federal court, although their actions are limited since they aren’t going to review how the lower court decided on facts. Instead, they just make sure there was no procedural bias or errors.
Not all work related injuries are covered by workers compensation laws. Here are some reasons a work related injury would not be covered…
1. If you arrived at work and were intoxicated, or were on the job and became intoxicated, you may not be eligible for workers comp benefits if you were injured. This doesn’t only apply to alcohol. Intoxication can also include legal and illegal drugs.
Example: You were prescribed medication to help you sleep at night and took more than the amount prescribed, and as a result you got injured. You may not be covered by workers compensation laws.
2. If you knowingly placed yourself in a dangerous position and the dangerous conditions had already been made clear to you by your employer, or the very nature of the area connoted danger, you might not be eligible for workers compensation benefits.
Example: You were properly advised by management to wear protective goggles while performing a certain task but you purposely ignored that advisement. You would risk denial of benefits.
3. If your injury was purposely self-inflicted there is an excellent chance you will lose twice. First by being denied benefits and second because you hurt yourself.
Example: You purposely take a heavy object and drop it on your foot causing broken bones. You’re probably out of luck.
4. If you were committing a crime while you were working and became injured you most assuredly will be denied benefits.
Example: You attempted to steal a puppy from a pet store and while hiding the little puppy under your coat you were seriously bitten. You would then have three problems: first suffering the serious bite, second the denial of benefits, and third is the arrest for theft.
5. Of course, if you were not actually working at the time of your injury you would be hard pressed to present a successful workmans compensation claim. This includes driving to and from work.
There is an exception to this exception though…
If you were asked by your employer to drive and pick up a part or other business item on your way to or from work, and while deviating from your normal path home you were involved in a collision. The deviated path collision and resultant injuries should be covered by workers compensation laws.
There are times when you may be legally permitted to avoid workers compensation laws and file a third-party personal injury lawsuit…
For example, you might be successful in a negligence lawsuit against your employer if your job requirements placed you in a potentially life threatening situation or one in which serious bodily injury might occur (and you didn’t previously sign a release of liability of course). This would also apply if you were injured by a defective product while on the job.
Example: A machine you work with exploded and the explosion could have been avoided if the employer had not ignored the recall notification from the manufacturer. In that case you might have a case against both your employer and the manufacturer of the defective machine.
Likewise, if your employer purposely allowed his workers compensation policy to lapse due to non-payment of premiums, you would be able to consider filing a lawsuit outside of the workmans compensation system.
Although there may be additional rare circumstances in which you’d be able to file a lawsuit, the above are some of the most frequent circumstances in which an employer can be sued.
Now that you have a basic understanding of workers compensation read these Tips for Filing Workmans Comp Claims.
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Visitor Questions on Overview of Workers Comp Claims
Is it still worker’s comp when two doctors disagree? My finger got caught in a shopping cart and then smashed on a conveyor belt while I was working in the state of Hawaii. I went to the E.R where they did an x-ray and my diagnosis was a closed, non-displaced fracture of the middle phalanx of my right middle finger, initial encounter. They put... Read More >>
Can’t get light duty after fracturing my big toe at work? I am in a situation where I injured my big toe at work. It turns out I have a hairline fracture in my toe. I was told by the doctor I could return to work on light duty and could only walk up to 3 hours a day. The injury was reported to work and... Read More >>