Workers’ compensation is a type of insurance policy that most private employers must obtain on behalf of their employees. In the event of an employee’s workplace injury or illness, the employer’s workers’ compensation policy will provide coverage of medical treatment and wage loss regardless of who was at fault. Additional benefits are available to compensate the family for a worker’s death.
While there are clear laws and policies regarding providing workers’ compensation benefits, issues often arise during the claims process that an experienced workers’ compensation attorney can help with. Here is a look at some of the services workers’ compensation attorneys provide to their clients.
Gathering Medical Evidence to Prove the Claim
Each year in the U.S., private employers pay around $100.2 billion in workers’ compensation insurance.
Like most types of insurance claims, the employer and the insurer both look to reduce payouts by investigating claims and determining:
- Whether the injury occurred at the workplace.
- Whether the injury resulted from drug or alcohol impairment, horseplay, or an intentional injury.
- The extent and type of medical treatment provided to treat the injury.
- The workers’ ability to recover from the injury and return to performing the tasks required for their job.
A workers' compensation attorney helps their client gather substantial evidence for the insurer to accurately assess the injury and costs of treating it.
The Types of Injuries and Illnesses Covered by Workers’ Comp
Workers’ compensation benefits are available to provide wage replacement and treatment for the following types of injuries and illnesses:
- Physical harm experienced on the job site or during the normal scope of the worker’s employment
- Mental anguish resulting from the injury or the accident that caused it. Seeking compensation for a mental condition that was the result of a workplace injury usually requires an accompanying work-related physical injury.
- Accidental injuries at the workplace, regardless of fault (with some provisions as discussed below in “Reasons a Workers’ Comp Claim Could Be Denied).
- Occupational illnesses are experienced as a result of exposure to a substance or condition.
The types of documentation that can help prove your claim include witness testimony from a coworker who saw the accident occur, the physician’s notes on what they learned about the injury through examination, copies of diagnostic or laboratory testing, and other information about the worker’s treatment or prognosis.
Independent Medical Examinations
Although many states—including Minnesota and Wisconsin—allow the injured worker to choose their treating physician, the employer’s workers’ compensation insurer often requests an independent medical evaluation (IME).
The American Medical Association explains that an IME is a medical exam provided by a physician of the insurer’s choosing to provide examinations.
An independent medical examiner has only a limited relationship with the worker to evaluate their injuries and the documentation provided by the worker’s treating physician.
Appealing the Insurer’s Denial of the Claim
All state workers’ compensation programs provide a process the injured worker can use to appeal the insurance company’s decision about their claim. For example, in Minnesota, injured workers who had their claims denied can file an employee claim petition form if they have never received any benefits. To appeal the loss of benefits, the employee should have their attorney call to talk to the insurer about the reason for the denial. The state also provides mediation services for injured workers, employers, and workers’ comp insurers to resolve the matter.
Reasons Workers’ Comp Denies Claims
Insurers deny workers’ compensation claims because:
- The worker or employer waited too long to report the injury to the insurer. Most states have a deadline to report an injury. For example, in Wisconsin, injured employees have 30 days to report their injury to their employer in most circumstances. Occasionally, an injured worker will be granted additional time—up to 2 years—to report the injury if they did not immediately know they were injured.
- The worker did not obtain prompt medical treatment for the condition.
- No witnesses could corroborate the claim that the injury occurred at work.
- The employer has reason to believe that the injury resulted from horseplay, drugs or alcohol, or deliberate actions to obtain workers' compensation. Insurers generally require workers to take a drug or alcohol test after a workplace injury.
- The injury did not occur at work. Workers’ compensation does not provide benefits for pre-existing conditions, and benefits are not available for those who suffered the injury during their commute to work (unless it occurred on work property) or while running personal errands off-property during a break from work.
- The injured worker sought treatment from an unlicensed healthcare provider or treatments considered unreasonable by the insurance provider.
Negotiating a Settlement for the Worker
Many people experience issues receiving benefits from their employer’s insurance provider after an injury. Others experience an initial approval of their claim and begin to see payments, only to have those payments stop for some reason. An experienced workers’ compensation attorney is trained in evaluating claims disputes and understands workers’ compensation laws that allow them to advocate for their clients.
Often, when there are disputes involving the provision of workers’ compensation benefits, those disputes can be resolved through a negotiated settlement, in which the attorney for the claimant works with the employer’s insurance provider to come up with a solution that all parties can agree to.
The benefits received through a negotiated settlement are determined based on:
- The workers’ existing injuries and the type of work-related tasks they can perform
- The medical expenses incurred by the worker to treat their injury, as well as estimates of their future medical expenses
- The extent of a permanent disability and whether the disability resulted in the need for partial wage replacement
- Whether the employer owes you for past temporary wage loss benefits, in addition to interest and penalties for the delay in payment
- How much income the worker was earning before they became injured
Many states have workers’ compensation laws that prohibit an employer from retaliating against the employee over filing a claim. Unfortunately, employer retaliation for workers’ comp claims is not an uncommon problem.
Some actions that an employer could take to retaliate against a worker for filing a claim include:
- Demoting the worker while they are away from work due to their injury
- Changing the worker's position or responsibilities without having a medically documented reason for doing so (such as if the worker can do tasks related to a different position, but not the one for which they were hired)
- Unwarranted disciplinary actions or even termination as a result of the worker filing a claim
Employers generally will not tell you when they retaliate against you for filing a claim. Often, workers find themselves written up for disciplinary issues after filing a claim when they were never the focus of corrective actions at work before the injury.
If you feel that your employer retaliated against you because you filed a workers' compensation claim, discuss the matter with your workers' compensation attorney as soon as possible.
Fighting for Your Right to Continue Receiving the Treatment You Need
The insurance provider and your employer each have commonsense reasons for wanting an injured worker to recover and return to work as soon as possible. Unfortunately, these needs don’t always align with the time it takes for the worker to recover.
If your physician or an independent medical examiner determined that you can return to work and you disagree, your workers' compensation attorney can help you consider your options for continuing treatment and develop a strategy for proving the need for continued treatment.
Reopening a Workers’ Compensation Claim
Sometimes, when an employee experiences a workplace injury, they are provided with medical coverage and temporary disability payments until they are well enough to return to work. However, weeks or months later, the injury flares up again, and they are required to miss even more work because of it. Most states allow workers to reopen their claim at any time within several years after an injury to obtain additional coverage of treatments and wage loss.
An attorney can provide:
- Guidance and assistance.
- Helping the claimant to show a worsening of their injury.
- The treatment necessary to assist the worker with their recovery through medical documentation.
Determining if You Have a Valid Third Party Personal Injury Claim
A personal injury claim generally compensates individuals for injuries they receive outside of work, such as injuries from a car accident or a slip and fall accident they experienced while shopping for personal goods at the grocery store.
However, one of the main purposes for creating workers’ compensation insurance policies was to compensate for injuries experienced in the workplace without the need for the employee to file a lawsuit against a negligent employer or coworker.
The personal injury claims process is only available to those injured in accidents at the workplace if the accident occurred as a result of negligence by a third party (not your employer or coworker).
Examples of the workplace accidents that can result in a third-party personal injury claim include:
- Traffic-related accidents occur during the normal scope of the worker’s employment due to a negligent motorist.
- Accidents on construction sites where multiple companies are working, and the cause of the accident was negligence by a worker from another company.
Individuals who are permitted to file a personal injury claim for a workplace accident have a wider range of expenses and impacts they can seek compensation for, including the psychological impacts of the injury, such as pain and suffering or loss of the enjoyment of life. However, they often have to wait longer for their compensation than a workers' comp claimant would.
Many workers' compensation attorneys also provide assistance and services for clients seeking compensation through the personal injury claims process. Other civil claims can arise from a work-related injury, including the ability in some states to file a legal claim against an employer for failing to provide a workers' compensation policy for their employees, employers who retaliate against employees for filing claims, and workers' compensation insurance providers who fail to respond to the claim promptly.
Workers’ Comp Benefits Are Too Important to Pursue Alone
Obtaining wage replacement and medical coverage after an accident isn't always easy for injured workers, who often find themselves overwhelmed by medical jargon, insurance requirements, and insurance requests by the insurer. A workers' compensation attorney is an experienced advocate who understands the process, the parts of the process that often lead to disputes or delayed payments, and the actions you can take to resolve these disputes.
If a workplace accident injured you, Contact an experienced workers' compensation attorney help you fight for your rights.