Common Reasons Workers’ Compensation Claims Are Denied
Workers who file a workers’ compensation claim expect their injury or illness to be fully covered by their employer’s insurer. Unfortunately, there are legitimate instances when an insurance company can deny a claim. Here’s how to reduce the risk of your claim being denied.
- Missed deadline
Taking too long to file the necessary paperwork with your employer can mean missing the reporting deadline, which is used by insurers to weed out fraudulent claims. For this reason, workers need to inform their employer as soon as possible after sustaining a work-related injury or illness. In some cases, it may be necessary to hire a workers’ compensation attorney in Orange County to help file your claim and obtain the benefits you deserve.
- The illness or injury wasn’t work-related
A workers’ compensation insurance company can claim the injury wasn’t work related if:
- There weren’t any witnesses when the injury occurred
- The injury was caused by a hobby or recreational activity, even if it occurred in the workplace
- The illness or injury was caused by a pre-existing condition
- The injury occurred while the employee was on their way to work or going home, or during a break
- The worker didn’t notify the employer when the injury occurred
- The illness or injury was due to horseplay
If the employee was engaging in horseplay, roughhousing, or joking when the injury occurred, the claim may be denied. The injury may be classified intentional if the employee broke safety protocols by engaging in reckless behavior.
- The employee was intoxicated or under the influence of illegal drugs
Workers who are injured while drunk or high on drugs do not qualify for workers’ compensation benefits. In these cases, workers may be terminated if a drug test shows they consumed alcohol or illegal substances while on the clock.
- The employee skipped medical appointments
It’s important to seek medical attention for an injury or illness as soon as possible. If the worker delays treatment in the hopes that the injury or illness will heal on its own, but their condition worsens or doesn’t improve, filing a workers’ compensation claim will likely lead to a denial of benefits.
- The employee accessed out-of-network medical care
When seeking medical care, employees need to check policy requirements and ensure they only see an in-network doctor. The employer should provide the worker with information about which doctors and facilities they can receive treatment from.
California Workers’ Comp Laws vs. Other States
In the US, workers’ compensation is regulated at the state level. This means states have widely differing workers’ compensation laws. In most states, with the exception of Texas, employers are required to carry workers’ compensation insurance.
Depending on the state, employers are required to make regular payments to a private insurance company or a state fund. These payments help cover the benefits paid out to injured employees. Benefits may include compensation for lost wages, medical bills, disability, and even death.
Typically, employers covered by workers’ compensation insurance must file a claim with the insurance company and forfeit their right to sue the employer in most cases. To avoid lawsuits, fines, and criminal charges, employers are required to know and understand local regulations governing employee rights.
How Workers’ Comp Laws Differ Across States
Generally, the differences between workers’ comp laws across the US can be broken down into the following questions:
- Is workers’ compensation coverage required or optional?
- Which employees must be covered by workers’ compensation?
For employees working in high-risk industries like farming and construction, workers’ compensation is generally required. Some states, like Wisconsin and Montana, distinguish between low-risk and high-risk industries to determine workers’ compensation requirements.
Other states, like Tennessee, Alabama, Missouri, and Mississippi, only require workers’ compensation for businesses that have at least five employees. In some cases, the five employees must be working full-time.
States like California, New York, and Connecticut allow employers to exclude high-level workers from workers’ compensation insurance as long as they provide the correct documentation. Corporate officers, directors, and LLC members may be excluded from workers’ compensation coverage.
States also treat general contractors and sole proprietors differently. In most states, sole proprietors aren’t required to carry workers’ compensation insurance.
California’s Approach to Workers’ Compensation Requirements
California has few exceptions for workers’ comp coverage, compared to other states. For example, every employer with at least one employee is required to carry workers’ comp coverage.
The state also doesn’t distinguish between high-risk and low-risk industries to determine coverage requirements. However, insurance companies will assign different rates to determine the insurance premium based on the risks in the workplace.
Thomas F. Martin, PLC Receives “Lawyer of the Year” Award From Best Lawyers®
Thomas F. Martin, PLC, a leading workers’ compensation attorney in Orange County, CA, has been recognized by his peers as the 2023 “Lawyer of the Year” in Workers’ Compensation Law – Claimants in Orange County. In addition, Martin will be highlighted in the 29th edition of The Best Lawyers in America® for his expert contributions to Workers’ Compensation Law – Claimants.
Every year, more than 12.2 million evaluations are submitted by top attorneys across the country. The transparent methodology is based on the fact that the best attorneys know who the best lawyers are. As a result, only the top 0.4% of lawyers earn the exceptional distinction of “Lawyer of the Year.”
According to the directory, “For more than 40 years, Best Lawyers has been regarded—by both the profession and the public—as the most credible measure of legal integrity and distinction in the United States. As such, recognition by Best Lawyers symbolizes excellence in practice.”
The directory does not charge a fee or payment to participate in the voting process, ensuring accessibility and trustworthiness. Winners of this year’s awards are eligible to participate in the exclusive voting process for next year’s edition.
Speaking of the recognition, Thomas Martin said, “It’s an honor to once again be named ‘Lawyer of the Year” by Best Lawyers. I believe injured workers deserve the highest quality of legal representation and it has been my commitment to serve them for more than 25 years.” He adds, “Justice is not easily achieved, but it’s worth the fight!”
Martin represents injured workers who have sustained chronic and career-ending injuries, and even the families of workers killed in a workplace accident. He has chosen to specialize in Workers’ Compensation to ensure clients receive expert representation.
To learn more about Thomas F. Martin, PLC, visit https://www.thomasfmartin.com/about/
Thomas F. Martin, PLC Recognized In The 2023 Best Lawyers in America®
Thomas F. Martin, PLC, a leading workers’ compensation attorney in Orange County, CA, has been named in the 2023 edition of Best Lawyers in America® for his professional accomplishments in the legal profession. Martin has received numerous awards from Best Lawyers in previous years for his leadership and expertise in the legal workers’ compensation field.
Winners are chosen through a survey completed by attorneys recognized in the previous edition of Best Lawyers. For the current edition, more than 12.2 million evaluations were analyzed, with only 5.3% of lawyers in the United States receiving recognition.
Best Lawyers CEO Philip Greer commented, “For more than 40 years our awards have garnered the respect of the industry as a reliable and unbiased resource to identify the top legal professionals, and we are proud to continue our globally respected purely peer-review methodology through these recognitions for lawyers at every level in their career.” Best Lawyers uses transparent methodology to identify the best qualified lawyers across the country and give them the honor they deserve.
“For over 30 years, I’ve had the privilege of protecting the rights of injured workers in Orange County, CA,” said Thomas Martin. “I’m grateful for the recognition I’ve received from Best Lawyers and strive to preserve the trust my clients and colleagues have placed in me.” Mr. Martin will be highlighted in the 29th edition of The Best Lawyers in America® for his high caliber work in Workers’ Compensation Law – Claimants.
Thomas Martin represents clients who have sustained a range of injuries on the job, from spinal cord injury and chronic pain, to amputation and brain injuries. He also represents families of workers killed in a workplace accident to ensure they receive the compensation they deserve.
To learn more about Thomas F. Martin, PLC, visit www.thomasfmartin.com/about]https://www.thomasfmartin.com/about
What To Expect When You Consult A Work Injury Lawyer
After a work injury, your time is more valuable than ever. Preparing in advance for the information and document that your attorney will need to file your claim will save you both time.
Documents to bring
The more prepared you are for the initial meeting with a work injury lawyer, the sooner benefits can be pursued. Try to bring the following:
- A brief description of your difficulties with the doctor assigned to you.
- A short description of your job duties
- Your most recent pay stub.
- The names of co-workers that may have witnessed your injury.
- The name of the work supervisor you reported your injury or condition to.
- The name and phone number(s) of the physicians you have seen for your injury or condition.
Discussion of the accident
Think carefully about how the injury or condition occurred. If machinery caused your injury, it is always helpful to have the name and model number of the machine. An Orange County workers’ compensation lawyer will ask you to provide as much detail as possible.
Questions to ask
When retaining an attorney, consider asking the following questions:
How long have you been practicing workers’ compensation law?
- Do you PERSONALLY handle my case, or do you rely on non-lawyers to handle court appearances and make decisions?
- Do you only practice work injury law, or do you try to manage other areas of law too?
- When was the last time you PERSONALLY attended a court appearance?
- How much time each month do you spend making TV and radio ads?
- Do you PERSONALLY negotiate settlements?
Next steps
Once the lawyer understands your potential case, they will let you know if they’re willing to represent you. When you retain a work injury lawyer in Orange County, you should feel confident you have the right lawyer for you.
The Role of a Work Injury Lawyer in Orange County
A work injury lawyer represents workers who have sustained injuries or an occupational illness. Their role encompasses a range of responsibilities that help to ensure the worker receives the benefits and compensation they deserve.
Determine Benefits Eligibility
Depending on the extent of the worker’s injuries, they may be eligible for the following benefits:
- Medical treatment
- Total or Partial Disability payment
- Permanent total or partial disability benefits
- Future Medical Care
- Job retraining voucher
Advise Clients on Workers’ Compensation Laws
A work injury lawyer in Orange County should be well-versed in California workers’ compensation laws and keep up with the latest changes to the system. An attorney recognized by other attorneys as ethical and knowledgable, such as Martindale Hubbell’s “AV Rating,” confirms a top attorney in the field.
Represent an Injured Worker
If you are qualified for the following benefits, an Orange County workers’ compensation lawyer will:
- Secure effective medical treatment for you, even if that means going to court to secure it.
- Thoroughly document the extent of your injury.
- Secure Temporary Disability payments so you can pay your bills while recuperating from your injuries.
- Document the extent of your Permanent Disability for the Judge.
- Secure the future medical benefits you are entitled to.
- Obtain a job retraining voucher.
- Enter into settlement negotiations to obtain a fair resolution of your claims.
- Conduct a trial if the employer refuses to pay the benefits you are legitimately entitled to.
A qualified Orange County work injury lawyer will serve as your “tour guide” through a complex system.
Key Skills And Knowledge
The more experienced an attorney is, the more likely they will be able to efficiently and successfully get you through your case. Look for:
- Does the lawyer practice many types of law or only workers’ compensation?
- Is the lawyer an administrator who does ads and supervises other lawyers and paralegals, or does the lawyer ACTUALLY APPEAR IN COURT routinely?
- Has the lawyer been recognized as an ethical and knowledgeable lawyer?
- Does the lawyer teach other lawyers how to represent injured workers effectively?
Injured workers should consider hiring a lawyer who limits the practice to workers’ compensation. Thomas F. Martin PLC has been a trusted name in Orange County workers’ compensation law for decades and has thousands of injured workers secure the benefits they deserve. Give Tom a call to schedule your free consultation!
Spinal Cord Injuries
The spine has 33 vertebrae, from the neck to the pelvis, with seven cervical (neck) vertebrae, 12 thoracic (upper back) vertebrae, five lumbar (lower back) vertebrae, five sacral (pelvic) vertebrae, and four coccygeal (tailbone or coccyx) vertebrae. Because the spinal cord connects the brain to the rest of the body, even slight damage to the spinal cord can lead to serious long-term health conditions and may severely impair motor skills.
Accidents at work can result in temporary, and even permanent, injuries to the spinal cord. Spinal cord injuries caused by slips and falls, falling objects, vehicle accidents, construction accidents and long term repetitive lifting motions may lead to partial or complete paraplegia or tetraplegia and severely limit a person’s ability to financially support themselves, and provide for their loved ones.
The Long-Term Effects of Spinal Cord Injuries
Complete paraplegia is a term physicians use to describe impairment in motor or sensory function, usually of the legs. Paraplegia can result from injuries to either the thoracic, lumbar or sacral regions of the spine. If all four limbs are affected by the injury this is referred to as tetraplegia (also commonly referred to as quadriplegia). Monoplegia is the medical term used when only one limb is affected.
Spinal cord injuries can also result in spastic paraplegia, resulting in sudden and uncontrolled movements of the affected limb(s).
Individuals that suffer a work injury that results in paraplegia or quadriplegia may experience complications, such as pressure sores, thrombosis, inflammation, nerve-related, and other health complications.
Symptoms of a Spinal Cord Injury
Individuals who sustain a spinal cord injury may experience the following symptoms:
· Numbness or tingling in the arms or legs
· Loss of function of the legs, feet, arms or hands.
· Severe pain in the neck and/or back
· Motor weakness
· Diminished coordination
· Loss of function of the foot (drop foot)
· Loss of bladder or bowel control
· Difficulty walking or maintaining balance
· Difficulty breathing
Permanent limitations may include:
· Bladder and bowel dysfunction
· Full or partial paralysis
· Difficulty breathing and/or need of respiratory support
· Infections
· Bedsores
· Pneumonia
· Chronic pain
· Headaches
· Mood swings or personality changes
· Sexual dysfunction
Important Steps to Take Immediately After a Spinal Cord Injury
To ensure maximum functionality and independence following a spinal cord injury, it is essential that a treatment and rehabilitation program be IMMEDIATE and customized to meet the unique needs of the injured worker. A team of professionals should be assembled, including physicians, nurses, and physical and occupational therapists.
Navigating the California workers’ compensation system following a spinal cord injury can be challenging for both the patient and family. An effective team of healthcare professionals is critical to optimize recovery, regain function, re-establish independence and may save delays and complications later.
It’s also important to consider retaining a workers’ compensation attorney to ensure the injured employee receives the appropriate medical treatment and compensation they are entitled to.
Injured Employees’ Legal Rights
Under certain conditions, employees who have sustained a spinal cord injury may have a legal basis to file an injury lawsuit against an employer or others that are responsible for the injury. A workers’ compensation lawyer can assist injured workers in documenting the potential liability of people and businesses that may have contributed to the accident or condition. Employees may have the following claims:
· Serious and Willful Misconduct. The employer was aware that the work conditions were unsafe and failed to take adequate safety measures.
· Inadequate or No Workers’ Compensation Insurance. The employer may be responsible for additional benefits even they have the workers’ compensation insurance required under California law.
· Third-party negligence. If a third party, such as another person or business, may be held liable for benefits IN ADDITION to workers’ compensation.
Why Hire Thomas F. Martin, PLC
Employees who have sustained a work-related spinal cord injury, or any other type of injury or illness, may be entitled to substantial benefits that cover the costs of medical care, physical therapy, transportation to care providers and wage replacement benefits. The harsh reality is that it is the job of a workers’ compensation insurance company to save as much money as they can on your claim. That’s why it’s so important to consider consulting with an experienced workers’ compensation attorney. The consultation is free.
Thomas F. Martin, PLC is a highly respected workers’ compensation attorney in Orange County, CA who has helped many clients obtain the benefits and compensation they truly deserve. If you’ve sustained a spinal cord injury, what many consider the best workers’ compensation attorney in Orange County, CA, Thomas F. Martin, PLC.
Occupational Disease and Workers’ Compensation in California
Workers in a wide range of industries are at risk of sustaining specific injuries that could require extensive medical treatment.
Workers can also sustain injuries described as “wear and tear” or “cumulative trauma” injuries over time.
Specific Injuries
A specific injury occurs on a particular date and time, like falling off a ladder or lifting something that hurts your back.
“Wear and Tear” or Cumulative Trauma injuries / Occupational Disease
Physical injuries – Workers in occupations involving repetitive motions, like lifting, bending, or typing, may be at risk of developing “wear and tear” or cumulative trauma injuries. The symptoms can take weeks, months, or even years to develop. A physician should provide an opinion that supports a relationship between work duties and the condition.
Internal injuries – Other injuries and diseases can occur due to various exposures at the workplace. Exposure to periods of prolonged stress can contribute to high blood pressure, heart problems, or even aggravate diabetes, for example. Exposure to dust, chemicals, dust, or fumes at work can cause damage to the lungs. Unfortunately, workplace exposure can even contribute to certain cancers.
Hearing loss – A common injury for workers who work around loud noise, like airport workers, heavy equipment operators, farmers, ambulance drivers, manufacturers, and factory workers are all at risk. An explosion at work would be work-related as well.
Skin conditions – Rashes and thermal burns can be caused by exposure to harmful chemicals and lead to pain and scarring. Occupations at risk for these skin injuries include:
- Lab workers.
- Farmers who use pesticides.
- Working around radiation.
- Miners.
Brain injuries – Exposure to dangerous chemicals and even infections like West Nile Virus and viruses like Covid -19 can cause severe and lasting damage to the brain.
The above are only examples. If you suspect you have been exposed to harmful circumstances at the workplace, consider consulting with a work injury lawyer in Orange County to gather the evidence necessary to present to a workers’ compensation Judge.
How To File A Claim For Occupational Illness
Unfortunately, the California workers’ compensation system is complex, particularly when gathering evidence of serious injuries. To document a specific, cumulative trauma injury, or occupational illness, consider a free consultation with our Award-winning Orange County workers’ compensation lawyer, Thomas F. Martin, PLC.
For over 30 years, Tom has assisted injured workers to secure the financial and medical benefits they deserve.
Recent Strike By Republic Services Sanitation Workers In Orange County
In November of 2021, over 400 sanitation workers employed by Republic Services at facilities in Anaheim and Huntington Beach voted to authorize a strike against the company. The workers’ contract expired in late September and was followed by multiple contract bargaining sessions.
Workers were concerned about excessive working hours and alleged persistent harassment in the workplace. Members of Teamsters Local 396 called attention to the large pay gap between the CEO and the company’s worker. In 2020, the CEO’s total compensation was over $12 million and 154 times the pay of an average worker. That same year, Republic Services grossed over $10 billion with $1.2 billion in net profit. In addition, the company spent more than $736 million buying back its stock.
Republic Services is the second-largest trash collection, disposal, and landfill company in America, with facilities in over 40 states. More than 7,000 Republic workers nationwide are represented by the International Brotherhood of Teamsters.
Ron Herrera, Secretary-Treasurer of Teamsters Local 396, said, “Teamsters working at Republic Services across Orange County are sending a strong message that they are ready to do whatever it takes to secure a fair contract. Republic Services needs to take negotiations seriously to ensure that these essential heroes who work hard to keep our cities clean and protect our environment get a fair contract.”
The Orange County strike had five members traveling to Republic’s hauling yard in New Orleans and putting up a picket there, while other workers extended the picket line to Republic’s recycling facility in Anaheim.
In December of 2021, more than 450 sanitation workers at Republic Services’ waste hauling yards in Anaheim and Huntington Beach ratified new collective bargaining agreements after a seven-day strike protesting the company’s unilateral changes without bargaining and threatening to retaliate against employees participating in union activity.
According to a press release, the new contracts include significant wage increases and other improvements.
Soon after the new contracts were ratified, more than 250 workers at Republic Services in San Diego went on strike demanding a fair contract.
Chuck Stiles, Director of the Teamsters Solid Waste & Recycling Division, said, “The strike in Los Angeles may be over, but Teamster members across America are fed up and will continue to take action until the company stops breaking the law and is willing to bargain fair contracts for these essential workers.”
In these increasingly frequent situations, I am reminded of the Warren Gunnels quote:
“You’re not a failure in life if you work for starvation wages with no benefits. You’re a failure in life if you are a business owner who depends on the exploitation of a poverty-wage workforce, no matter how many yachts and mansions you own. It’s time to redefine success in America”.
The Dangers of Working Outdoors During California Wildfire Season
California wildfires are now a yearly event.
Nearly four million people work outdoors in California. Industries like agriculture, construction, landscaping, and utilities rely on employees to work outdoors, even during wildfire season.
Though employers are required to take steps to protect outdoor workers from breathing in harmful levels of smoke, such as providing N95 masks, California’s Division of Occupational Health and Safety (known as Cal/OSHA), cited employers just 11 times between July 2019 and October 5, 2021. Only two agricultural employers were fined by CAL/OSHA for failing to provide enough respirators or effective training to employees exposed to wildfire smoke, according to agency data.
Excessive exposure to wildfire smoke can cause eye and throat irritation, persistent coughing, wheezing, difficulty breathing and even certain types of cancers. Exposure to just 2.5 parts per million can even lead to reduced lung function, heart failure, and even early death.
An investigation by The California Newsroom linked the rise of wildfire smoke to sharp increases in hospitalizations for heart and lung conditions in California. The investigation also revealed a dramatic rise in prescriptions for the asthma medication albuterol as the number of “smoke days” increase. There is simply no denying the correlation.
Nayamin Martinez, executive director of the Central California Environmental Justice Network said, “I always find it very ironic when the agencies brag, ‘Oh, we have more stringent rules [than] the entire nation.’ Well, those rules are out there. But if you don’t enforce them, then there’s nothing good out of them.”
A recent survey of more than 300 agricultural workers in the San Joaquin Valley conducted by Central California Environmental Justice Network found that nearly 60% of farmworkers weren’t provided N95 masks nor did they know what “N95s” even were. About 45% said they didn’t know what protections they had from California wildfire smoke.
The fact that so many at-risk workers are not even aware of the type of masks that would provide enhanced protection is proof that employers are not stepping up to their responsibility when it comes to educating and protecting their workers.
CAL/OSHA is taking steps in the right direction. The agency has begun posting videos and other training materials on its website in both Spanish and English with the goal of protecting workers, and providing safety information that employers are not.
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