10.21.2012

How to Navigate Worker's Compensation Claims and How It Really Works



Workers Compensation, a personal story from Marian
I have been involved in a worker comp suit for over 5 years. It is not an easy thing to navigate, nor is it quick. Here are some points based on my experience.
You have to get hurt AT THE JOB to file a suit, and even then, still it can be hard to have a claim accepted. For example, I had previous back problems, but went into spasm on the job because my work aggravated my problem. I filed a claim. My work denied the claim, and then said they would terminate me when my short term disability had ended. That is ILLEGAL.
Short term disability is a State provided benefit, not Worker’s Compensation (WC). I collected 8 months of State Disability before my case was accepted and then the Insurance CO. that is your employers WC carrier has to reimburse the State for the money you have collected. By the way, your State Disability benefits come from your own personal account which you have paid into for the years you have been employed. Once your account is depleted, your benefits end.
The Insurance Company and your Employer will more than likely fight you every step of the way. It is business and it is a law suit. They fight to win. If you have a real case, you must get an attorney. Try to get a referral. WC attorneys do not make the money they once did and so they try to spend as little time with you as possible, which leaves you in the dark and confused and frustrated much of the time. Between that and the humiliation- coupled with the fact that the system makes you feel like you are lying and trying to get something for nothing,
It is not for the faint-hearted. If you do not have a working spouse or financial resources behind you to sustain you through the process it will be difficult to hang in there for the duration. The WC Insurance carrier will stall, ignore requests for your treatment, deny treatment, and make your doctor appeal the treatment requested. You have to be able to take that in stride and know that it is part of the process.
You may be required to go through a deposition. I did. You may be required to go to an AME (agreed medical examiner) or QME (qualified medical examiner). These doctors are supposed to be the neutral party that examines you; they determine the legitimacy of your injury. Some of these doctors are perhaps a little more biased towards patient’s rights or employer’s rights. An experienced attorney should be able to direct you towards the best choice for you and your case. What this Physician says, “goes. If it goes your way you will begin collecting your WC benefits, which like your State Dis. is based upon your earnings. You can get these benefits for two years max. If you are still disabled after two years and have funds in your State Dis. account, you can re apply for that money.

Settlement
There are two halves to this: compensation for your injury / Future Medical
Settling them both at once is called C&R or Compromise and Release.
Based upon the ratings determined by WC law, the extent of your injuries, and the portion of those injures which are considered preexisting, a percentage of total disability will be assigned to you. That % = a $ amount. That dollar amount will be paid to you over month installments not to exceed $529 every two weeks, until the total liability is exhausted. If your total disability is 70% or more, you are entitled to a 'life time pension'.
I have been unable to find out what amount of money that is, not for lack of asking.
You may settle the above mentioned portion of your case (btw, standard attorney fees are 18% of that amount off the top) and keep your future medical open. I chose to do this because of my multiple injuries and my worries about being able to afford insurance premiums. This is a whole separate topic and a nightmare in itself. Once your % of disability is determined the Ins. Co. will want to pay you off so you will go away. They will offer a C&R, a dollar amount far less than what you expect, or that seems adequate for your future medical. The carrot they dangle is that they will give you one check for everything rather than pay you every two weeks. They count on your financial dire straights and exhaustion so you will settle. I think the attorneys are pretty much ready to be done with you too, and it is the most money for their amount of time. Just my opinion.
(BTW, you can change attorney's mid course if you have a good case, and they have to work it out amongst themselves. You don't even have to fire the old one in person, the new one files paperwork. One change is probably the limit, too little money for them to divide up.)
 
Reopen
You can reopen your case within five years of your date of injury if your work related injuries have worsened or it you have other injuries as a result. For example, you have to take a lot of pain meds and you become addicted, or medications make your teeth start to weaken and cause problems, or you become depressed because of your disability. Be careful here, you can not become depressed because your parents die, or your kids get hurt, ONLY as the result of your injury. You can't sleep because of your pain, now you have insomnia and are depressed. I have filled for a reopen. They are fighting it, of course.

Settling Future Medical Later
I am in the process of this. It is hard being in the system and I want out. I have been awarded Social Security Disability, so while relieved, SSDI opens up a whole new can of worms, the MSA or Medicare Set Aside. (More on this another time.
Start a File, Keep everything. Get copies of every doctor’s report. Ask them to mail you a copy of the doctor’s dictated notes: labs, x-rays, MRI's, everything. You will need it if you file for SSDI for sure. Label and file all documents. It will be much easier if you start right at the beginning, really. Trust me, you want to do this.  Marian F., October, 2012