Medical Benefits If you suffered a work injury, your employer is obligated to provide "reasonable medical care" for treatment of your injury. This includes everything from emergent care, to diagnostic testing, physical therapy, surgery, etc.
Your private health insurance policy language excludes coverage for injuries that are compensable under a state's workers' compensation act. Therefore, unless you are paying your doctor cash, your only avenue to receive medical care is through the workers' compensation insurance carrier.
Since the workers' compensation carrier is paying the medical expenses, they have a statutory right to manage your medical care. This is frightening because the insurance carrier's attention is always on cost-saving and maximizing corporate profit, rather than providing the injured worker with the best healthcare possible.
Fortunately, in Iowa, if employer provided medical care is unreasonable, there is a quick remedy available via a petition for alternate care. This is an expedited action in which an injured worker can ask the industrial agency of the workers' compensation commissioner to order the employer to authorize certain medical care. This is an important tool, particularly when employers delay treatment, ignore providers' recommendations, or cherry pick disingenuous providers far away from the claimant, due to their tendency to minimize and deny claims.
Often for different reasons an employer will deny liability for a claim. This is not all bad because it obligates your private insurer to cover costs and frees you to select your own providers. In this case, the injured worker may file a petition before the Agency, and a contested case proceeding, (called arbitration,) will be set before a deputy commissioner.
In a denied liability claim, the private insurer will have a subrogated claim of recovery against the inured worker's successful workers' compensation claim, for any money it has paid for treatment related to the work injury. Most private insurers including medicaid will negotiate a reduction of their lien. If the injured worker is a medicare recipient, and there is a medical opinion that significant future medical care is likely, settlement negotiations can get quite complicated because medicare will not permit shifting the burden of these costs from the insurance carrier to it. Medicare set asides are usually required.
Medical records are extremely important in any claim. What an injured worker says or doesn't say will influence how the medical records come out, which can have major impact on the outcome of the claim. Therefore, an injured worker should always be thorough and articulate as well as completely accurate when talking to a provider. Temporary Wage Replacement Benefits The authorized treating medical provider may give the injured worker temporary work restrictions, e.g. no lifting more than 10 pounds. The injured worker should notify his/her employer of these restrictions. The employer must decide whether to accommodate the worker by offering suitable work within these restrictions, or send them home.
If the employer decides not to accommodate the restrictions, the injured worker will receive a TTD (temporary total disability) check once a week from the insurer. The weekly benefits rate depends on several factors, but it is usually about 2/3 the average gross weekly wage of the injured worker for the 13 weeks prior to the date of injury.
If the employer accommodates the worker's restrictions, but pays him/her less wages, the worker will be entitled to TPD (temporary partial disability). TPD is 2/3 the difference in wages the worker earns after the date of incident compared to his/her average weekly wage prior to the date of incident.
If an inured worker is fired for cause or voluntarily quits, the insurer no longer is obligated to pay temporary wage replacement benefits, though the obligation remains for medical and permanency benefits. Unfortunately some employers employ mendacious tactics to cheat their workers out of temporary wage replacement benefits. They may create "makework" that is cruel, overly boring, or unpleasant, in an effort to get their injured worker to quit. For example, cleaning toilets all day, waving a sign in front of a business all day in freezing temperatures, etc. Unfortunately, there is not much that can be done to push back against this. Applying for unemployment benefits is sometimes warranted in the most egregious cases where a theory of constructive termination may work.
An injured workers' entitlement to temporary wage replacement benefits will expire when their authorized treating provider releases them at maximum medical recuperation or if their temporary work restrictions are eased and the employer chooses to accommodate them. Sometimes in the course of an insurer's investigation they will deny liability, though they have already paid some weekly indemnity benefits. In this case, the insurer must give 30 days notice before cutting of benefits. Permanency Benefits Injured workers are compensated for the permanent loss of use of their body, and sometimes for a reduction in earning capacity. Once the authorized provider releases the claimant at maximum medical recuperation, he/she will give the claimant an impairment rating. This will be a number with a % sign. In Iowa there is a statutory value of many different body parts. For example, the complete loss of an arm is worth 250 weeks. Your impairment rating will dictate the value of your claim for a scheduled injury. For example, if your authorized doctor gives you 1% impairment rating for your arm injury, the insurance company will voluntarily pay out 2.5 weeks of permanency benefits.
Your employer provided doctor will probably give you an impairment rating that you feel is unreasonably low. You may have had a serious injury that required surgery, physical therapy, injections, etc., and you still have significant weakness, pain, cramping, range of motion deficits, etc. Fortunately, the injured worker is entitled to receive an independent medical examination from a doctor of their choice. This IME doctor will examine the injured worker, review the medical records, and write a report wherein a more reasonable impairment rating is opined. The injured worker may then demand the insurance company pay out indemnity consistent with the IME doctor's opinion. For example, if the IME doctor opines a 25% impairment to the arm, the worker could demand 62.5 weeks of permanency benefits. In most cases, the injured worker will have to meet somewhere in the middle of the two differing providers if they want to get their case settled pre-litigation.
When an injury occurs to a non scheduled member, permanency benefits are based on earning capacity loss. The best way to explain industrial disability is by hypothetical example— Claimant is a 50 year mechanic. He has worked as a mechanic his whole life and earns a good living. His job duties have always included frequent heavy lifting, bending, stooping, crawling, climbing ladders, etc. He suffers a herniated disc in his lumbar spine which requires a laminectomy. The surgery has a poor-fair outcome. His doctor opines that he has permanent work restrictions of sedentary only work. Because all of the skills he has acquired over the course of his career do not transfer to sedentary occupations, he has arguably suffered a huge industrial disability. While he was earning $30 an hour as a mechanic, he may now have to work for less than half that in a new occupation. In a case like this, a large industrial disability award should be awarded.
Unlike tort claims, pain and suffering damages are not available in workers' compensation.