Workers Compensation

The answer is dependent on the reason why your claim is denied. There are many reasons why a claim may be denied and each case is different. Some reasons why your claim may be denied include the insurance company/employer claiming (1) you were not an actual employee; (2) you gave notice of your workers’ compensation injury only after your employment ended; (3) there is insufficient medical evidence to substantiate a claim; (4) your claim is barred by a statute of limitations; (5) that your injury did not arise out of or in the course and scope of your employment, etc. We are sometimes able to request a hearing and go to trial on the issue of why your claim is denied to ask the judge to determine whether or not your claim is compensable. If a judge determines your case is compensable, you may be able to obtain benefits.

There must be medical evidence indicating you’re temporarily disabled in order for you to obtain Temporary Disability benefits. In addition, most insurance companies will not pay temporary disability benefits if you are not treating with a doctor within the employer’s Medical Provider Network. However, when an employer fails to provide medical treatment, leaving you to obtain treatment outside of the Medical Provider Network, TD benefits may still be obtained.

Unfortunately, the insurance companies make it extremely difficult to obtain medical treatment. Oftentimes employers do not even respond to demands for basic information as to whom the workers’ compensation insurance carrier even is and many employers do not comply with the California requirement to register information regarding their workers’ compensation insurance carrier. Once the insurance company is determined, we usually have to demand information regarding their Medical Provider Network and where we can locate their list of doctors. Once we have tried to locate a doctor, we are almost always unable to make an appointment without prior authorization from the insurance company. Once authorization is obtained, an appointment is made.

Just as it is difficult to even schedule an appointment with a physician, it is even more difficult to get treatment authorized. We believe that approximately 90% of the requests for authorization for treatment, medication, etc., by the doctors are denied by the insurance companies. If the request for authorization for treatment is denied and your claim is an accepted claim, the issue can go through the Independent Medical Review process to try to overturn the insurance company’s decision to deny the requested treatment.

When you are released to return to work by your Primary Treating Physician, Panel Qualified Medical Examiner, or Agreed Medical Examiner, you are usually provided with work restrictions which take into consideration your injuries and the need to avoid reinjuring or causing further injuries. If your employer has available work within the work restrictions given to you, you should try to work with the work restrictions. If your employer offers you modified work and you refuse to accept it, any permanent disability benefits you may be entitled to could be subject to a 15% decrease. If your employer does not offer you any work within your work restrictions, you may be entitled to a 15% increase in any permanent disability benefits to which you may be entitled. Your employer may be required to accommodate your restrictions. If they terminate you based on accommodations needed then our firm’s Employment Department may be able to assist further.

Your employer should attempt to accommodate any work restrictions you may have and if they are unable to do so, you may qualify for a re-training voucher. If your employer is not cooperating with you or your are terminated based on work accommodations needed, then our firm’s Employment Department may be able to assist further.

There is no set schedule on your when you case is going to settle and offers to settle your case are controlled by the insurance companies. Generally, a physician will declare you “permanent and stationary” prior to any offers being made, although that is not always the case. In addition, not every case will settle. Many cases will proceed to trial for a judge to determine what you are to receive in your case.

There are many factors that determine what your case is worth, including (1) the “whole person impairment” which is given by your Primary Treating Physician, Panel Qualified Medical Examiner, or Agreed Medical Examiner when you are declared “permanent and stationary”; (2) apportionment attributes to other factors (such as pre-existing injuries, degenerative issues, non-industrial causes, etc.); (3) any defenses raised by the insurance company concerning the compensability of your claim; (4) your age; and/or (5) your occupation, etc.

It depends on the needs in your case. However, our attorneys spend most of their time out of the office fighting for our clients, but have a support staff to assist them in answering your questions. Our support staff is trained to answer many of the questions you have concerning your case and acts as a liaison between you and your attorney. If your question can not be answered at the time of your call, we will do our best to obtain the answer or resolution to the issue. In addition, should your deposition be scheduled or any hearing in your case scheduled, you will have an attorney present with you.

Pursuant to California Labor Code Section 3751(b), “If an employee has filed a claim form …, a provider of medical services shall not, with actual knowledge that a claim is pending, collect money directly from the employee for services to cure or relieve the effects of the injury for which the claim form was filed …”