Compensación para Trabajadores

Workers’ compensation insurance covers you for injuries you suffer on the job, including injuries that happen suddenly in one moment and those that gradually happen over time.

1. If you think you have an injury, you should report it right away to your employer and go to a doctor. You can file a claim through your employer or your doctor. The employer cannot require you to see a specific doctor and cannot discourage you from filing a claim.
2. Once you file a claim, the insurer has 60 days to investigate the claim and decide whether to accept or deny the claim. During the investigation, you have to cooperate with the insurer’s requests, meaning completing forms, giving a recorded statement, and maybe going to a medical exam the insurer schedules.
   a. During this investigation time, you may receive wage replacement benefits (called time loss or temporary disability) if a doctor takes you off work, or restricts your ability to work and your employer does not have a light duty job for you.
   b. Generally, the insurer does not pay medical benefits while it is investigating.
3. If the insurer denies your claim, you must appeal and ask for a hearing within 60 days of the denial date. The hearing will be scheduled within 90 days from the date you appeal. You will not receive any more benefits unless you win at hearing or settle with the insurer. It is complicated to prove a denied claim, because you need both your testimony about what happened, and a very technical opinion from a doctor that explains how the injury caused your medical conditions. It is almost impossible for a claimant to win a hearing without an attorney.
4. If the insurer accepts your claim, you will receive all benefits of the workers’ compensation system for the accepted conditions. The insurer will keep paying time loss and medical benefits during your recovery. Your doctor (called your “Attending Physician”) is in charge of all referrals to medical treatment and whether you can work regular or light duty. You need a medical doctor; nurse practitioners or chiropractors can be your Attending Physician only for a limited time. Generally, you get to choose your own doctor, but the insurer can require you to select a doctor from their lists (called a “Managed Care Organization” or “MCO”).
5. If your doctor thinks that you have additional medical conditions from the work injury other than what the insurer accepts, you can ask in writing for the insurer to accept the additional conditions. Then the insurer has another 60 days or accept or deny those additional conditions. If they are denied, you need to appeal and request a hearing, but the insurer will still provide benefits for the accepted conditions.
6. At some point in your claim, your doctor will declare you medically stationary, which means there is no more treatment or time that will improve your accepted conditions. It does not necessarily mean you are 100% better. Unfortunately, medicine cannot always cure all symptoms and people often still have pain or limitations at the end of the claim. When you are medically stationary, the insurer will close your claim and evaluate you for permanent impairment, which is compensation paid to you for losses like range of motion, strength, and ability to use repetitively the injured body part. Some surgeries also result in compensation at this time.
7. If the doctor releases you to return to regular work, the employer has to offer you your job back, subject to some limitations. But if you have permanent impairment that prevents you from returning to your regular job, the employer can offer you a permanent light duty job or the insurer evaluates you for vocational benefits, where they may send you to school to learn a new profession and pay you time loss while you are in school.
8. After the claim is closed, you may be able to get palliative care, which is treatment to help with symptoms from an injury with permanent impairment and to help you keep working. The doctor must ask for pre-authorization for this treatment. You can also have the claim reopened if your actual condition is worse. The only way to reopen a claim is for a doctor to sign a form requesting reopening, so if you think your condition is worse after closure you should go to a doctor, and then call us.

Some of the ways that we help you through the claim process are:

1. Continually reviewing your claim to ensure you are receiving all the benefits and treatment you deserve.
2. Working with your doctors to make sure you are getting all of the treatment you should.
3. Explaining all of the paperwork you will receive from the insurance company and communicating with them on your behalf so you do not have to talk to them.
4. Settling all or part of your workers’ compensation when that is the best choice for you.
5. If your employer discriminates against you or fires you because of your claim, we can also help you pursue a claim against the employer.
6. In some cases, you might also have an additional claim against a third party, if a person or company other than your employer caused your injury.
7. While each case is different, our focus is always on you. We will work to obtain the maximum benefits and compensation to help you and your family through the injury so you can return to normal life.

At Hollander, Lebenbaum & Gannicott, we are here to help you with your claim, no matter where you are in the process. If you think you need an attorney or you just have questions about the claim process, give us a call!