Ideally, if you are hurt on the job, workers’ compensation should pay your medical bills and for any lost time because of that injury. If you are hurt bad enough, workers’ compensation should also pay your permanent disability, for future medical care and even for re-training.
In reality, sometimes this doesn’t happen. This post will attempt to explain the reasons why a workers’ compensation claim will be denied or delayed and what injured employees need to do preserve their rights.
- Lack of information: In order for a claims administrator or insurance company to pay a claim, they need to determine if it is covered by workers’ compensation. At a minimum, this means that they need some medical records documenting the injury. This can take time. If a doctor has given work restrictions, this means that the claims adjuster needs to contact the employer to find out if those restrictions can be accommodated. Even assuming everyone is being honest and diligent, this process may take a few weeks. The general standard is to give an insurer three to four weeks to investigate a claim. I would advise that injured employees be civil with employers and insurance adjusters. This can be difficult if you are like many Americans who live paycheck to paycheck, but a loss of temper can compromise your case. It’s difficult to be patient, but the fair employers and/or insurers will make up lost time pay and will pay you a reasonable amount of benefits without dispute and without the involvement of a lawyer.
- You aggravated an old injury or chronic condition: To be clear, if you make an old injury or chronic condition worse, that is covered by workers’ compensation in Nebraska. However, this may not be understood by a claims person in a state where there is a different standard of causation. This fact is also not widely understood by most employees or managers, which can lead employers to deny coverage and discourage employees from reporting such injuries.
- Your injury came on from overuse or repetitive use rather than from a one-time incident: Arm, hand and even back injuries are very common from repetitive activity. These symptoms usually come on over time, and employees can’t pinpoint an exact injury date to employers or doctors. Under Nebraska law, such injuries are covered by workers’ compensation. But again an unscrupulous insurer and/or employer can use these facts to argue to you that your injury is not covered by workers’ compensation.
- You delayed seeking medical treatment: Delaying going to the doctor can hurt your workers’ compensation case, because it raises the suspicion that you hurt yourself outside of work. The delay doesn’t even need to be all that long. It’s a red flag if you claim you were hurt on a Friday then seek treatment on a Monday. There are all sorts of legitimate reasons for some delay, such as the inability to make an appointment, wrongfully thinking you need to ask permission to see a doctor from your employer, seeking treatment with company nurses first, or even thinking an injury will improve on its own. A lawyer can make those arguments with some success, and you should contact one if this is an issue in your case. But the longer you wait to see a doctor, the more likely it is your claim will be denied.
- You didn’t tell your supervisor you were hurt, or you didn’t fill out an accident report: If you are hurt at work, your employer has a duty to report to the state of Nebraska and the Occupational Safety and Health Administration (OSHA) that you were hurt. You also have a duty to inform your employer as soon as practicable. Cover yourself, and report the injury. Even if your employer doesn’t have a form or a formal human resources department, send a text or e-mail to your boss telling that person what happened and what kind of injuries you have.
- You initially denied you had a work injury: Some employers will tell you that they will take care of the injury themselves and not turn it in to workers’ compensation. In some cases, employees are afraid to turn in injuries. In other cases, an employee has been led to believe that an injury isn’t covered because of the factors listed in points 2-5, so that worker turns the claim over to private insurance. The problem with this outcome is that for a serious injury you can get stuck with paying a lot of money out of pocket, which can be almost impossible to pay if you aren’t working and not receiving workers’ compensation benefits. Even worse, some health insurers will reverse payment if they get an indication your bills should have been covered by workers’ compensation. Some companies have private disability policies that might allow you to collect some benefits, but those policies will also deny benefits if they have some indication that there was a workers’ compensation claim.If you are in this situation, you need a lawyer for your workers’ compensation claim. You also need a lawyer who knows creative ways to turn the tables on employers and insurers who completely deny benefits to their employees. Some of my most professionally satisfying cases have come from turning the tables on employers who, for lack of a better word, jack around employees who make some mistakes in how they handled their workers’ compensation claims.
Even if you have done several things to hurt your workers’ compensation claim, a good lawyer can take actions to get justice on your claim.
- Your employer didn’t fill out an accident report or filled it out wrong: Not all denials or delays are due to mistakes made by employees. Employers drop the ball as well. That’s why you want to cover yourself with your own written report as well as see a doctor as soon as you can and be sure to tell that doctor how you were hurt.
- You were treated by a physician assistant or nurse practitioner: Some insurers and/or employers believe that physician assistants and nurse practitioners cannot testify in a workers’ compensation case in Nebraska. I strongly disagree, but the issue has never been definitively decided by an appellate court. An aggressive employer and/or insurer will use this as an excuse to not pay benefits. A lawyer can help fix this issue by asking a supervising physician or D.O. to give an opinion in your case.
- You went to see your own doctor rather than the employers’ doctor: Unless your employer gives you notice AFTER your work injury, you have the right to be treated by your doctor. You don’t have to see the doctor at the clinic where your employer sends you to be drug tested after an injury.
I despise few phrases more than “workers’ compensation doctor.” Any doctor can treat you for a workers’ compensation injury. A “workers’ compensation doctor” or an “occupational medicine doctor” is just a doctor who is happy to fill out the extra paper work required in a workers’ compensation claim. Usually these doctors work hand in glove with employers and insurers. Sometimes this works out for employees, but many times it doesn’t. Unscrupulous or unknowledgeable insurers and/or employers will deny care to employees who pick their own doctors. Sometimes employers will take action against employees as well. In cases like this, you need a workers’ compensation and employment lawyer.
- Your employer blames you for your injury: Unless you were intoxicated when you were injured, the issue of fault is irrelevant in a workers’ compensation claim. If your employer is denying your claim based on you being at fault, you need a lawyer for your workers’ compensation claim and one that can evaluate a potential employment-law claim.
- You are being denied benefits because you were fired or quit: Like the issue of fault for your injury, the fact you were fired or quit post-accident should have little impact on your workers’ compensation claim, but you should contact a lawyer who can advise you on workers’ compensation and employment law.