What is the Workers’ Compensation System?
The workers’ compensation system was established by the Vermont Legislature in 1915 in order “to compensate and protect employees” who suffer personal injury in the course of employment. According to the Department of Labor “almost all of Vermont's 350,000 workers must be covered by the system…” The system is supposed to protect injured workers. It provides the right to claim money and the right to receive services
Who are the VIPs (Very Important Persons) in the Workers’ Compensation System?
(1) You, (2) Your Attorney (Friend), (3) Your Medical Providers (Friend), (4) Your Employer (Friend usually), (5) The Insurance Adjuster (Not a Friend even if "friendly"), (6) Nurse Case Manager (Not a Friend usually), (7) Independent Medical Examiners (Not a Friend), (8) Department of Labor (Neither Friend nor Foe), (9) Vocational Rehabilitation Counselor (Friend, depending on who it is)
Is my Injury Covered Under the Workers’ Compensation Act?
Virtually any injury arising out of, and in the course of, employment is covered under workers’ compensation. There are only a few exceptions, such as the case of intoxication, some horseplay, some failures to use required safety equipment. Work injuries frequently involve obvious damages to the spine (low back, the neck), and injuries to major joints such as shoulders, knees, wrists, and elbows. Other injuries are not as easily proven, but can be devastating in disability, such as mild traumatic brain injury, nerve injury such as chronic regional pain syndrome (CRPS), and mental/emotional injuries such as post-traumatic stress disorder, panic disorder, and depression.
What About Preexisting Conditions?
We all know the phrase “the straw that broke the camel’s back.” That camel would have kept going if not for the one new straw. That’s as close a description as any in understanding how workers’ compensation treats preexisting conditions. You can come to an employer with a bad back and successfully perform your job. If your duties for that employer, however, “aggravate” that condition and cause you to become disabled, it is known as an aggravation at work and it is covered under workers’ compensation.
What Benefits Can I Claim in my Case?
1) Wage Benefits 2) Medical Expenses 3) Vocational Job Retraining 4) Permanent Partial Disability Benefits 5) Permanent Total Disability Benefits. Note on Wage Benefits: The rate is 2/3rds of your average pay. Payment is weekly. Annual COLA ("Cost of Living Adjustment") is required to be made effective each July 1st. If you have dependent children, an extra $10.00 per week, per child is paid on wage benefits. Note on Medical Benefits: There is never a deductible. There are no co-pays. There are no time limits on treatment. You have the right to choose your own physician under Vermont Department of Labor Rule 12.1200. Miles traveled to medical appointments are reimbursable if the trip is farther than your roundtrip distance to work. If it appears that your prescriptions will continue for more than four months, the insurance company has to set up a direct billing system so that you don’t have to continue to pay out-of-pocket and wait for reimbursements.
How Long Do I Receive Weekly Wage Benefits?
Weekly wage benefits (2/3rds of your average weekly wage) will continue as long as the following two conditions are both met: (1) you have not yet returned to work, and (2) you are still improving from your work injury. When you stop improving, you are at “medical end result” ("MER"), also sometimes referred to as “maximum medical improvement” ("MMI"). The Department of Labor defines “medical end result” in Rule 2.1200 as “the point at which a person has reached a substantial plateau in the medical recovery process, such that significant further improvement is not expected, regardless of treatment.” In ordinary terms, it means the point when the physician says “You are about as good as you are going to get” from the work injury. Adjusters often try to cut off wage benefits by scheduling a so-called "independent medical examination" to obtain a so-called “independent” opinion that the injured worker has already reached medical end result.
How Long Do My Medical Benefits Last?
Tue or False: “Once you return to work,you can’t see the doctor anymore.” This is false. Medical care for your work injury is for life, as long as two conditions are met: (1) the treatment is reasonable and necessary; and (2) the treatment is still “related to” the original work injury. If you have not seen a physician for quite some time, or if there has been some "new incident" which may have made the injury worse, the insurance adjuster may attempt to deny further treatment as no longer "related to" the injury. Often, the adjuster will hire a so-called "independent" doctor which it has chosen to deny the claim. However, the issue will depend on expert medical opinion from your physician versus theirs.
What Are The Major Mistakes I Need to Avoid?
1. Waiting a Little While Before Reporting Injury 2. Assuming a Previous Injury is None of The Insurer's Business 3. Failure to Keep a Log of Good Faith Searches for Work 4. Missed Medical Appointments 5. Failure to Have a Current Doctor's Note on Work Restrictions 6. Failure to Communicate with Providers with Completeness 7. On a Good Day, Trying but Overdoing it. Note: Keep your own communication log of the adjuster’s calls, dates and times, and exactly what the adjuster told you or promised; without your own communication log, you will be at a disadvantage if the insurance adjuster later has a “different memory.” Note: If video surveillance is “inconsistent” with the medical record of restrictions, the insurer will not hesitate to make it appear as a case of dishonesty and fraud. If you are having a “good day” or feeling like you might be able to do more, it is wise to first consult with the treating provider before risking both health and case.
What Do I Need to Know About Settlement?
It is not always in the injured worker’s best interests to settle, particularly if it is still early in the medical recovery process, and especially if additional surgery is expected. Settlement involves risks. Settlement involves rewards. Many advantages can be enjoyed through a successful effort to negotiate a lump sum settlement. The advantages include not simply the cash payment, not even simply the relief, peace of mind, and sense of regaining control over one’s life by parting ways with the insurance company and the workers’ compensation system, but also financial advantages such as maximizing other benefits, like Social Security or long-term disability, and opportunity and freedom to work or search for work at one's own pace and on one's own terms.
Are There Other Claims or Benefits I Should Consider Besides Workers’ Compensation?
Injured workers cannot sue the employer for a work injury unless the employer was uninsured or intended the injury. But injured workers are not prohibited from suing others -- workers may file a civil lawsuit against any other person or other company whose carelessness caused the injury ("third party" case). Damages in a "third party" case are not limited to benefits, but include money damages include pain and suffering, loss of life's pleasures, past, present and future. In addition, consider potential benefits beyond the scope of workers’ compensation. • Short-term and long-term disability • Loan disability benefits (car or mortgage) • Social Security Disability benefits • Local municipalities and town assistance to disabled persons. • Charitable societies, church organizations, and other partial assistance. • Vermont Medicaid (VHAP) • Medicare • Unemployment compensation • Vocational Rehabilitation services from the Vermont Department of Labor.
