Employees have the right to receive agreed-upon pay (including pay for all hours worked) and benefits, in accordance with government regulations and laws.
Medical Treatment "Reasonably Required" The standard in the California workers' compensation system for when treatment shall be provided by the employer is "medical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." That language is taken directly from Labor Code Section 4600. The Labor Code is the set of laws that govern workers' compensation in the State of California. As noted below, what is considered "reasonably required" must be established by your doctor in the form of a Request for Authorization or RFA and must then be approved through the utilization review process, also explained below. Medical Provider Network (MPN) Treatment must be within your employer’s Medical Provider Network (MPN), unless you have a valid pre-designation signed by your treating doctor prior to your injury date. The employer and their claims administrators get to hand-pick the doctors within their network, so the doctors they select often are located at industrial clinics or otherwise have a loyalty to the insurance company so as to stay on the list. That doesn't mean that all, or even most, of the doctors on the MPN list are bad. However, you want to be a strong advocate for yourself by ensuring your doctor is providing the care you need by establishing the "medical necessity" of any treatment requested. If you do not care for the initial MPN doctor, you are at liberty to transfer your care to any doctor in the appropriate specialty that is in the employer's MPN. Request for Authorization (RFA) Required by Your Doctor Any treatment requested by your doctor will need to be placed on a required "Request for Authorization" (RFA) form. On the form, and any attached accompanying documentation, the treating physician is required to refer to the medical guidelines established by the Department of Industrial Relations in explaining why a particular treatment is medically necessary. If the doctor fails to cite the proper guidelines, or leaves out important information requested by the guidelines, it is highly possible the treatment will get denied by the utilization reviewer. Utilization Review Unfortunately, treatment is subject to utilization review where a doctor hired by the insurance company, a doctor you never meet, reviews all treatment requests by the MPN doctor for “medical necessity.” It is important your doctor be familiar with, and cite, the various treatment guidelines to improve your chances of getting treatment authorized. Independent Medical Review If treatment is denied through the utilization review process, an appeal can be filed, known as Independent Medical Review (IMR). Strict time lines are in place for an appeal to be filed. If treatment is denied, you want to have a discussion with your doctor immediately as to whether the doctor will produce the documentation that may have been missing on the RFA, information that may have resulted in the treatment being denied. You want to make sure your doctor addresses the specific reason or reasons outlined in the utilization review denial in the form of a supplemental report. You then want to make sure the supplemental report, and any other relevant reporting, is forwarded to the Independent Medical Review company. Your doctor also has the option to attempt to have a "peer to peer" conversation with the utilization review doctor to explain why the treatment is medically necessary. IMR can overturn the utilization review denial. However, if iMR "upholds" the denial, the denial is valid for 1 year. Your doctor can re-request the treatment after 1 year. However, it is important your doctor include in the additional request whatever information may have been missing from the initial request. Otherwise, another denial is likely.
Immediately report the injury. Employers will always fight a case that is not immediately reported. If not documented, it gives the company ammunition to allege that the accident did not occur on the date and time later claimed and that the injury actually occurred off the job. Some employers will fire employees for failure to timely report an injury. In addition, many many times employers will tell employees that if the accident isn't reported, then a claim cannot be pursued. This could not be further from the truth! Ohio law allows a claim to be filed within one year of the date of injury. Obviously, a reported accident is more likely to be covered than an unreported accident. However, many workers experience aches and pains throughout their shift that typically go away. There are occasions where that simple muscle strain thought to be nothing at the time could later be determined to be something much more serious, such as a herniated disc or a rotator cuff tear in the shoulder. This is why I advise people at my seminars "when it doubt, file a report." In addition, there are occasions that an injury doesn't happen with a specific event, rather gradually over the course of time. These "wear and tear" injuries are covered in Ohio and most other states. Some of the conditions that are wear and tear type claims are carpal tunnel syndrome, impingement syndrome of the shoulder, ulnar neuropathy and other hand, wrist and shoulder disorders. My best advice to workers that experience symptoms of hand, wrist, knee, ankle or shoulder pain to complete an incident report at that point in time where you start believing you will require medical attention. Again, not all injuries involve a specific on the job accident. In order to best protect yourself and your family, seek to complete the report as soon as possible after the pain starts. Obtain coworkers statements. Request anyone that was near you when the incident occurred to complete a statement confirming what they know and saw. Too many times, even after completing an incident report, the employer will somehow lose the report or fail to offer it to you or your attorney. Having a witness statement confirms your version of the events and another way to get your claim covered. Seek immediate medical attention. Seeking medical attention soon after the injury not only starts you on the road to recovery but also confirms that the incident occurred as you described, Make sure you are consistent in your description. Many employers will attempt to discredit injured workers where the description of accident on the injury report is inconsistent with how the injury was described to your physician. Most likely, you would have told the same story but medical providers are busy and may not fully listen to your story. Thus, it is very useful to require medical personnel to read back what they documented to ensure that it is accurate. This is another way to make sure your claim gets allowed! File a claim with the Ohio Bureau of Workers' Compensation. In order to obtain benefits for your injury, a claim application must be filed. As noted above, the application must be filed within one year of the date of injury. Filing the application starts the process of obtaining a claim number and ultimately a determination as to whether your injury is valid. Seek legal advice. Most attorneys that represent injured workers provide free initial legal consultations. Seeking advice doesn't mean hiring an attorney. If you are unsure about what to do and want to know your legal rights in your claim, the best place to go is an attorney that specializes in this area of practice. You are under no obligation to sign with that attorney. Most lawyers will gladly answer your questions and concerns about your injury and what to expect. Many times, after listening to a potential client, I advise them that they do not need an attorney at the present time but of course leave the door open to return should they run into problems with their claim. My firm, Schaffer and Associates, collectively has over 50 years of experience representing those injured and disabled and will gladly discuss any questions, concerns or problems you may have with the pursuit of your claim!
Why You Should Talk to a Workers' Comp Lawyer The ultimate goal of a worker’s comp lawyer is to represent you to make sure you get treated fairly by your employer and insurance company and get compensated fairly for your injuries. Contact us today to learn more about how we can help. They can handle things like gathering medical records, taking depositions, doing legal research, drafting any motions or other requests, and will represent you in any legal proceedings. One of the biggest reasons to hire a worker’s comp lawyer is that compensation laws are complex. You May Not Understand Workers' Comp Law Chances are, you aren’t an expert in worker’s comp laws. And unless you need to be, why would you really know the ins and outs of them? The reality is that they are extremely complex, vary by state, and vary by industry. An experienced personal injury attorney who specializes in these types of cases knows the laws, knows what an employer can and can’t do, and can help you navigate the process. Your Employer May Deny Your Claim There are instances when an employer may deny your worker’s comp claim. Even though they have insurance to cover your expenses, employers don’t want too many claims, as that means their premiums will likely increase. If your employer refuses to cooperate or denies your claim, you’ll need a lawyer to advocate for you. A worker’s comp lawyer can appeal the denial for you and negotiate with your employer and the insurance company. The Insurance Company Will Try to Settle Businesses and insurance companies are concerned with their bottom line. And in the case of a worker’s comp claim, they want to pay out as little money as possible. The insurance company will often try to settle with you, often offering you only a fraction of what you are entitled to. If the settlement offer is extremely low or if your employer outright denies your claim, you may need to file a lawsuit. You May Need to File a Lawsuit If you aren’t getting anywhere with your employer and the insurance company, your attorney may need to file a lawsuit. Many people simply give up at this point, accepting whatever the insurance company offers or just accepting the denial and moving on. You shouldn’t give up though, and continue fighting for what is rightfully owed to you. An attorney will prepare the necessary documents to file a lawsuit and then handle the litigation process. Most worker’s comp attorneys only get paid if they win the case, so you can rest assured that they take cases that they think they can win.
Even If You Get Fired, You Are Still Entitled to Benefits Georgia is an at-will employment state, meaning your employer can fire you for any reason (or no reason at all) unless you have a contract specifying the term of your employment. In general, even if you get terminated, you do still have the right to receive worker’s compensation benefits after your employment ends. You Have the Right to Pick Your Doctor Employers must provide and post a list of appropriate doctors that you can pick from. If they don’t post it, and you can prove this, you can choose your own doctor. Your employer and insurance company can’t just send you to any doctor they choose without your consent. You Can Fight a Denial of Your Claim If your employer or their insurance company denies your claim, you don’t just have to accept that decision and move on. Even if they approve your claim but later decide to stop paying benefits, you can fight that as well. An experienced workers’ comp lawyer can help you decide what your best course of action is and represent you in a lawsuit. Medical Expenses Don’t Just Include X-Rays or Doctor Visits You aren’t just entitled to have your x-rays or doctor’s visits paid for. Under Georgia workman’s compensation rules, you are also entitled to transportation, prescriptions, reimbursement for mileage, and treatment for depression or anxiety, as long as the conditions are related to your injuries sustained at work. You Do Not Have to Settle The insurance company and your employer are concerned with their bottom line, which means they want you to settle for the lowest amount possible. You do not have to accept a settlement from the insurance company, especially if they offer you much less than what you are entitled to. If you settle, your case is closed and you can’t reopen it. This is another situation where an experienced attorney can help you decide if the settlement is fair and advise you on the best course of action. There Are Time Limits On How Long You Can Receive Benefits You can only collect benefits for 400 weeks. Even if you are still unable to work, benefits end at this point. The only exception to this is if your injury has a catastrophic classification. In that case, you can receive benefits beyond 400 weeks. Catastrophic injuries include spinal cord injuries, severe brain or closed head injuries, second or third-degree burns, blindness, and other severe injuries. You Have the Right to Have a Workman’s Comp Attorney Most attorneys will speak to you about your case at no charge to you. They’ll help you understand if you have a case and whether an attorney will benefit you. You have a right to an attorney during the workers’ compensation process, so take advantage of this.
Document everything (and keep copies) Medical records are the best source of communication between insurers and the companies involved. Your insurer will use this information to determine whether your claim is covered and how much money you will receive. For these reasons, it’s important to keep detailed, accurate records. Make sure that any condition, injury and medical problems you may have are documented in your medical records, otherwise the insurer may ask question whether your conditions are connected with your injury. Remember, your previous medical conditions won’t be paid for so if you don’t have records of your medical history documented, you could face a headache. Watch what you say Believe it or not, things you say after your injury can impact your worker’s comp payout. NEVER speak directly with someone from an insurance company. These adjusters are trained to gain your trust in the hopes that you can say something incriminating that will lower or even disqualify your worker’s compensation claim. The goal of these adjusters is to pay out the bare minimum. Also, avoid posting anything on social media about your injury or case. You may think you are just sharing your point of view with friends and family, but insurance adjusters and attorneys have ways of seeing these posts and can try to use them against you. Watch what you do Adjusters will monitor you to see the extent of your injury. As you are healing there will be good and bad days. Avoid any public activities that could make it look like you're less injured than you are. Remember, adjusters won’t stop at hiring a private investigator — they may also speak to your co-workers, doctors, friends and neighbors. In addition to not writing about your case on social media, also be careful not to post pictures that may make you appear healthier than you are.
Injury must occur while working • An injury must arise out of and in the course of employment to be a workers’ compensation case in New Jersey. This means you must have been injured while on the premises, or if off premises, in the direct performance of your duties on a trip for work. There are exceptions, but they are few. Seek counsel if you have questions! • Purely personal conditions or injures may NOT be compensable. If you set fire to your hair with a cigarette, sitting at your desk, the Supreme Court of New Jersey has termed that a purely personal risk and injury, not ordinarily subject to workers’ compensation. Report your accident at once • If you are injured in the course of your employment, report it immediately. Don’t wait to see if it clears up on its own. Make a report to your employer, to a person responsible for taking that report. Don’t just mention it to a foreman or secretary. Find out who takes injury reports, and make a formal report. Be specific. • Your injury must be reported to your employer within ninety days, or it can be barred. You must file a formal claim petition with the State within two years of your last payment of compensation for your claim (medical, temporary disability or permanency) or your rights will be barred. Workers Compensation carrier information • Your job has a legal duty to prominently post the identity of the workers’ compensation insurance carrier on the premises. Take note. If your employer will not report your injury, report it yourself. You are protected from retaliation by Statute (34:15-39.1) and anyone who testifies for you, in support of your claim, is also protected by that law. Medical Treatment • Seek medical treatment at an emergency room if your employer will not direct you to a company physician. Take great care to inform the ER staff that you were injured at work, and precisely how you were injured. Records cannot be corrected once an error or omission occurs. • Your company has the right to direct your medical treatment, but that is secondary to their duty to provide you with treatment. The company doctor is YOUR doctor, and must treat you like any other patient. • The company may send a nurse to your medical appointments. Demand that the nurse stay outside, and demand that you be part of any discussions with the doctor. The doctor is YOUR doctor, and has a physician patient relationship with you. It is NOT appropriate for your doctor to talk to other people about your case, without informing you. • Do not fill out long forms, questionnaires, or releases for your entire life of medical treatment simply because you are told to do so. Filing a workers’ compensation claim does not waive all of your privacy rights. Consult a lawyer before giving up your privacy! • You do not have a right to a second opinion under New Jersey law. A lawyer, however, can usually negotiate for a second opinion, or send you for a second opinion and file a Motion to force the insurance company to treat you more adequately. Temporary disability benefits • You are owed 70% of your wages as temporary disability while you are certified as unable to return to work by your authorized physician, and under curative treatment. There is an annual maximum. There is a legal minimum, adjusted annually. Insurance companies often miscalculate this rate. Only your lawyer can help you get the correct rate. • Your employer must offer you light duty if you are returned to light duty by your doctor while under treatment. If they do not, or offer you light duty inappropriate to your condition, they must pay you to stay out. Monetary compensation at the end of your case • You have the right to money for your injuries if they are permanent and cause anything more than an absolutely minimal disability. Scars, hearing loss, vision loss, breathing problems, and many other occupational diseases are covered by workers’ compensation. A specialist in workers’ compensation can advise you as to how to recover money for your injuries. • Counsel fees in workers’ compensation cases are set by the Judge, and ordinarily, your employer ends up paying most of the fee. Medicare, Medicaid, Social Security Disability, private health insurance • Workers’ compensation is complicated: It involves Medicare, Medicaid, and potential problems with your health insurance, if bills are misdirected. Only someone who really knows the system can prevent interruption of your other benefits, or liens on your case. Final words • Get help early. Don’t wait until you fall behind on your bills because of late payments. Don’t wait for unpaid bills to harm your credit rating. And above all, do not let two years pass before filing the paperwork that keeps your case alive.