What To Expect With Your Workers' Comp Claim

From Filing A Claim To Maximum Medical Improvement

The early stages of a workers' compensation case are dominated by three major issues: getting the insurance company to accept a claim, getting the injured worker appropriate medical treatment, and making sure the injured worker has temporary disability benefits while he or she is unable to work. This stage begins with filing a claim, and ends when the injured worker's primary treating physician writes a permanent and stationary report indicating the injured worker has reached maximum medical improvement.

Often, insurance companies will accept liability for claims immediately. Other times, they will delay accepting liability until after conducting an investigation. This investigation may involve subpoenaing an injured worker's medical records, or a formal interview under oath called a deposition. The case is not necessarily on hold until an insurance company accepts a claim because some doctors will agree to treat patients on a lien basis (The doctor doesn't get paid for his or her services unless the injured worker wins his or her case). Additionally, there are often other government benefits available as a substitute for temporary disability. If an insurance company denies a claim, the injured worker can request a trial on the narrow issue of whether the injury occurred in the scope of his or her employment, although a judge may decide to wait until the end of the case and hear all the issues at the same time.

Even when an insurance company accepts liability for a claim, there can be disputes over what treatment is reasonable and necessary. When an insurance company refuses to authorize treatment or diagnostic testing requested by the injured worker's doctor, the dispute is decided by a process called Utilization Review. If the Utilization Review decision favors the insurance company, the injured worker can appeal for a second review called Independent Medical Review. Except in very limited cases, all Independent Medical Review decisions are final and cannot be appealed to court.

There can also be disputes over temporary disability. One common temporary disability dispute is whether the injured worker is capable of working or not, and therefore eligible for disability at all. When these types of disputes arise, they are usually resolved by a report written by the injured worker's primary treating physician. When either party objects to this report, it is resolved by a neutral doctor. When the insurance company and the injured worker agree to a neutral doctor, this doctor is called an Agreed Medical Examiner. When the parties need to ask the government for help selecting a doctor, the doctor is called a Qualified Medical Examiner. Regardless, this doctor reviews medical reports, examines the injured worker, and writes a report about whether the injured worker is eligible for temporary disability benefits or not. If the parties still cannot agree, either party may request a trial on the narrow issue of temporary disability, although a judge may decide to wait until the end of the case and hear all issues at the same time.

From Maximum Medical Improvement To Settlement

The second stage of a workers' compensation claim focuses on permanent disability, job vouchers and future medical care. It is also where any issues that were not resolved in the first part of the case are settled. It begins when the injured worker's primary treating doctor writes a permanent and stationary report. This report indicates that the injured worker has reached maximum medical improvement, describes any residual disability the injured worker has, recommends future medical treatment that will be necessary to protect the health of the injured worker going forward, and whether the injured worker can return to his or her old job, or needs to find a new line of work. If both parties agree with the primary treating physician's conclusions and recommendations, the case can settle. If either party objects, the issues are resolved by a neutral doctor called an Agreed Medical Examiner. When the parties need to ask the government for help selecting a doctor, the doctor is called a Qualified Medical Examiner. Regardless, this doctor reviews medical reports, examines the injured worker, and writes a report about whatever the parties disagree about. Any discrepancies between the neutral doctor and the treating doctor are settled by the parties before trial, or resolved by the judge at trial.

Future Medical Care And Reopening Cases

The last stage of a workers' compensation case revolves around continuing to provide the injured worker the medical care he or she needs, and possibly reopening the case if an injured worker's condition worsens.

When there is a dispute over what treatment is reasonable and necessary at this stage of the case, it is handled just like it is in the first stage. If an insurance company refuses to authorize treatment or diagnostic testing requested by the injured worker's doctor, the dispute is decided by a neutral doctor through a process called Utilization Review. If the Utilization Review decision favors the insurance company, the injured worker can appeal for a second review called Independent Medical Review. Except in very limited cases, all Independent Medical Review decisions are final and cannot be appealed to court.

If an injury deteriorates in a way or to an extent that the workers' compensation doctors did not expect, a case can sometimes be reopened by petitioning the court for a finding of new and further disability. This process must be started within five years of the day of the injury. The result can be an increase in permanent disability benefits.

Contact Us

Please contact the Law Offices of William S. Lindheim to schedule an initial consultation. If you are an injured worker, there is never a charge for a consultation with an attorney at our firm. You can reach us by phone at 844-260-0131, or you can complete a short online contact form. We handle cases throughout Los Angeles, Orange County, Riverside & San Bernardino and Ventura counties.