Montemaggi Law - Workers Compensation Attorneys


27 Jun 2013

10 Common Misunderstandings About Workers' Compensation

Posted by Paul J. Antonowicz
1)You can't get medical treatment because your case is "closed" - This, by itself, is not a reason that you would be unable to get medical treatment. Medical treatment that is related to your original injury is covered for life as long as it follows the requirements of the Workers' Compensation Board's Medical Treatment Guidelines. There can be legitimate questions about the relationship of treatment to the injury, but a case is never "closed" for medical treatment unless you enter a special type of agreement. If you are told this by your doctor or the insurance company, immediately report it to your attorney or the Workers' Compensation Board if you are not represented. 2)Reducing or stopping payments after a judge has directed payments. The insurance company cannot reduce your payments without a new decision once a judge has set the rate of payment unless you return to work or your doctor says you have no disability. If your doctor says you have a lower level of disability than what you are being paid or the insurance company doctor says your disability is less than what is being paid, the insurance company must write to the Workers' Compensation Board and the Board must issue a decision on the rate before the rate can be reduced or stopped. They also cannot stop your payments because you have a new injury or for any other reason, except the ones mentioned above, without a decision from the Workers' Compensation Board. If the insurance company stops your payments and it is not for the reasons allowed, immediately contact your attorney or contact an attorney about getting represented. 3) You will lose all of your benefits if you are not released to return to work. Sometimes, an insurance company representative or even your own doctor will say that you have to be released to work or you will lose your benefit. Obviously, the insurance company and your employer want you to be released to return to work as quickly as possible so that they can reduce or stop your payments. It is perfectly legitimate for them to ask your doctor about your ability to return to work. However, it is not okay for them to use false statements of the law or otherwise pressure your doctor to release you to work before it is appropriate. 4) You will lose all benefits if you do return to work. This is something that claimants frequently believe will happen. It is not true. First, covered medical benefits continue for life. Second if a claimant returns to work making less money because of physical restrictions, there is a reduced earnings benefit that can be paid to help cover the difference in earnings. Third, you are almost always better off financially, psychologically and often physically when you are active and working. 5) You are required to allow a "nurse case manager" to physically attend doctor's appointments with you. It is certainly true that a nurse case manager can be very helpful in many cases. Their job is to facilitate treatment and obtain quick authorizations. However, this can be accomplished over the phone and there is no need for a stranger to intrusively attend doctor's appointments with you. We do not believe that in-person nurse case management is ever appropriate and often is simply an attempt to gain direct access to your doctor and influence his or her opinions. You do not need to agree to this and you should object when the insurance company assigns such a case manager. 6) The insurance company has to pay mileage for trips to the Workers' Compensation Board, pharmacy, your attorney's office, etc. The reimbursement for mileage in Workers' Comp cases is limited to trips for actual medical treatment and for exams by insurance company doctors (IMEs). They do not reimburse for every trip you need to make to pursue your case. 7) Every medical treatment/referral requires prior authorization from the insurance company. Some doctor's will tell you that they can do nothing without authorization. This was never true. Under the Board's Medical Treatment Guidelines, many types of treatment are pre-authorized. However, this is a tricky issue because not all types of injuries are covered under these guidelines and the guidelines require authorization for certain types of treatment that are not mentioned even for injuries covered by the guidelines. For types of injuries that have not yet been included in the guidelines, prior authorization is required for any treatment exceeding $1000. However, the best thing is for your doctor to familiarize himself with the guidelines and follow them. This can avoid many problems in getting authorization for treatment to getting treatments paid for once they have been completed. You should also make sure that your doctor is familiar with Workers' Compensation requirements. Sometimes doctors who are unfamiliar with the system will plow ahead with treatment that needs prior authorization and then cannot get paid. 8) The insurance company must pay claimants every two weeks on the same day and if they do not payments are late. This is not true. While payments generally are made on a biweekly basis, the Worker's Compensation law actually allows insurance companies a lot of leeway in when they make ongoing regular payments. Payments are not considered late until a few weeks after you might normally expect them and there is no requirement that the insurance committee pay on a particular day or maintain a consistent schedule. The insurance committee can change the schedule of payment and might sometimes miss a payment by error. This does not mean that payments are late and you should not expect your payments to come every two weeks like clockwork. 9) Every Worker's Compensation case results in a lump payment at some point. This is absolutely not true. Some types of Worker's Compensation injuries, usually to arms or legs or feet or hands, will usually result in a lump payment once no further active treatment is necessary. This is not really considered a settlement because it is simply with the law allows and those cases often resulted no additional money being paid once the appropriate part of the case is reached. However, most Worker's Compensation claims do not result in an automatic settlement or lump payment of any kind. It is possible to enter into a settlement agreement with the insurance carrier called a Section 32 agreement. However, everyone involved in the case has to agree to a number and no one is required to agree. 10) I will get money for my pain and suffering as a result of my Workers' Compensation injury. This is absolutely not true. Workers' Compensation does not have any award for pain, suffering or loss of lifestyle. The benefits in Worker's Compensation are designed to compensate for necessary medical treatment and limited replacement of wages. Other than mileage reimbursement for certain things, there is no other monetary benefit in Workers' Compensation.