When a person is injured at work, it can be one of the most frustrating and difficult experiences with the legal system. The injured worker suddenly has a hundred questions and no one to answer them. The employer tells the employee one thing, the Workers Compensation insurance carrier says another, and a medical examiner hired by the insurance company may be telling the employee something altogether different. If what you see or are told does not make sense, or you are unsure of your rights, you should consult with an experienced workers compensation attorney.

Who Can Make a Workers Compensation Claim?

Employees who are injured on a job can make such a claim. This seemingly simple statement is in fact a very complex inquiry. Are you an employee, or will your employer contend that you were an independent contractor? Will your employer concede you were "on the job," or will the employer contend that you were on your own time? Are you "injured," or is your condition one that was not caused by work, but just coincidentally happened at work? These are just some of the issues that can come up in a workers' compensation case.

What Is Covered Medically by Workers Compensation?

An employee that is injured at work is entitled to reasonable, necessary, and related medical expenses to treat the work-related injury in accordance with the Workers Compensation Act as amended by Acts 44 and 57. In other words, you do not have general health insurance that pays everything on an indemnity basis. A workers' compensation carrier will only pay those treatments and procedures that are reasonable, necessary, and related to the work injury. Furthermore, an employer/workers compensation carrier, in most circumstances, is able to direct the injured worker's treatment for the initial ninety days of the injury. An employer/carrier's right to direct treatment depends on certain posting requirements.

Nothing is more frustrating to an injured worker than being told a helpful treatment is not being approved. Many times, an employer/carrier engages in a course of conduct aimed at preventing or minimizing treatment without following the provisions of the Act. Then, of course, there is the "Independent" medical exam to which an employer/carrier sends the injured worker. It is absolutely amazing how many injured workers are found not to be in need of treatment or not injured at work by these "Independent" examiners. An injured employee has medical treatment rights. What the employee does not know will hurt him/her. An injured employee has many rights, including the right:

  • To a second opinion before 90 days expire

  • To file a petition to have the medical treatment sought approved

  • To file a petition to correct the injury description

  • To treatment with a provider of his or her selection after 90 days

  • To appeal any decision of Utilization Review regarding necessary treatment

  • To refuse medical exams by the employer if more than once every six months

Injured employees should not fear that they have no rights. If you feel that you have questions concerning your rights, you should contact an experienced workers' compensation attorney.

What Wage Benefits Are Covered by Workers Compensation?

An injured employee is entitled to two-thirds of any wage loss caused by a work-related injury up to the statewide maximum average weekly wage as determined by the Department of Labor and Industry for the year of the injury. Many times, a dispute arises as to what is included in wages. For example, a car allowance is part of wages, but health insurance is not. Overtime worked in the past is required to be used in the calculations, not just base pay. Commissions and bonuses are included in the calculations, as is additional part-time income that by virtue of your injury you can no longer perform.

What Do You Do When Your Compensation Carrier Denies Your Claim?

If your employer/workers' compensation insurer denies a claim, you need to see an attorney to see if it is an invalid denial. You have a limited time to file a claim to overcome this denial. The sooner you act, the better off you will be.

What Do You Do When Your Compensation Carrier Tries to Stop Your Wages?

If you are receiving workers compensation wage payments, the carrier cannot stop your weekly checks without an agreement by you to do so, or by an Order from a Workers Compensation Judge. What usually happens is that the employer/carrier gets the idea that you can work, maybe not at your old job, but somewhere doing something. The first thing the carrier/employer usually does is have you examined by a physician of its choosing. If the physician states in a report that you can return to some form of work, then the employer/carrier sends you a "Notice of Ability to Return to Work." This warning notice advises you of your alleged ability to work and the legal consequences of not returning to work.

The next thing the employer/carrier might do is to make a specific job offer at the employer with or without restrictions as outlined in the medical report. If there is no offer of a specific job, then the employer/carrier might hire a vocational examiner to find work available in the marketplace, who in turn will notify you of these "job opportunities." Or the employer might choose to have the vocational examiner assess your earning capacity based on doing a labor market survey of available jobs in the regional economy that fit your medical restrictions.

Once any of these evaluations occur, the employer/carrier will likely file a petition to reduce or stop your compensation payments based on the medical or vocational opinions. This will be in the form of a Petition to Modify, Suspend, or Terminate benefits. In addition, the employer/carrier will be asking the Judge to immediately stop payments. This is called a Supersedes Request. If it is granted, then your benefits will stop. You obviously need an attorney before the Supersede hearing, which is scheduled within a 45-day period of time. You should contact an experienced workers compensation attorney in our firm as soon as the request for a medical exam occurs.

Why Else May I Need an Attorney in a Workers Compensation Case?

You may need an attorney for some of the following reasons:

  • To correct the amount of weekly benefits

  • To correctly describe the injury for the records

  • To fight unreasonable requests for medical exams

  • To defend attempts to reduce or eliminate benefits

  • To reinstate previously stopped or reduced benefits

  • To get medical bills paid

  • To get appropriate medical treatment

  • To help you negotiate the resolution of your claims to a lump sum

Lump-sum settlements are called Compromise and Release Agreements. The correct valuation of a claim for a lump sum settlement is something that needs experience and understanding of how the system works.