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.
What To Do After You’ve Been Injured At Work
Though safety laws have helped reduce the rate of injury at work, accidents still happen. When they do, workers need to know what steps they should take to ensure their injury is properly documented and treated.
- Seek emergency medical treatment
If the injury is life-threatening, workers should seek emergency medical care. Let hospital staff know the injury or illness is job-related and when you’re in a stable condition, contact your employer for further instructions.
- Report the injury or illness to the employer by filing a claim form
It’s important to file a claim with your employer’s workers’ compensation company as soon as possible to ensure your injury or illness is covered. Request a claim form from your supervisor and fill out the “employee” section of the form. Sign and date the form, submit it to your employer, and keep a copy for your records.
The employer will then complete the “employer” section and forward the completed form to their workers’ compensation insurance company. They should also give you a copy of the completed form for your records. The insurance company then has 14 days to mail a letter providing the status of the claim.
- Check the status of your claim
If the claim was denied, workers have the right to challenge the decision. But it’s important to file a dispute as soon as possible. Hiring a workers’ compensation attorney could help increase the odds of a successful claim. In California, workers must file an Application for Adjudication of Claim at the DWC office in the county where they live or the county in which they were injured.
Once the form has been filed, the DWC will send a notice confirming the form has been filed and provide a case number.
- Attend all medical appointments
While the claim is being processed, workers need to attend all medical appointments. Missing an appointment could give the insurance company a reason to deny the claim and withhold benefits.
- Hire a workers’ compensation attorney if your claim was denied
Certain factors make it difficult for injured workers to secure benefits. In these cases, they may need the expertise of a workers’ compensation attorney.
If you’ve been injured on the job, contact Thoms F. Martin, PLC, the best workers’ compensation attorney in Orange County, for legal representation.
7 Tips For Staying Safe In The Workplace
Regardless of whether you work at a desk or operate heavy machinery, the workplace poses safety hazards that could lead to injuries. To stay safe and avoid injuries, here are a few tips every employee should keep in mind.
- Use equipment, machinery, and tools properly
Don’t think that you can figure out how to use equipment properly on the fly. No matter your experience level in the industry, it’s important to approach every new piece of machinery with caution. Take the time to learn how the equipment works and take the necessary steps to protect yourself and others.
- Report unsafe conditions immediately
If you see unattended machinery, loose cords, cluttered spaces, broken glass, spilled liquids, broken lights, or uneven surfaces, report these safety hazards to your manager or supervisor.
- Stay hydrated
Staying hydrated helps you stay alert and focused. Keep a bottle of water nearby to remind yourself to drink water regularly.
- Practice good posture
Whether you’re sitting for long periods of time or lifting heavy objects, it’s important to use the right posture. Use an ergonomic desk and keyboard to minimize strain on the wrists and arms. Remind yourself to sit up straight and keep the shoulders in line with the hips when moving objects. A habit of poor posture will strain the back, neck, and shoulders, leading to serious injury.
- Take regular breaks
Working nonstop may seem noble, but in fact it’s counterproductive. Without regular breaks, employees tend to get distracted, careless, and fatigued, which increases the risk of injury. Take short walks and avoid using your phone during your breaks.
- Be aware of surroundings
If you’re working in a busy environment with many moving objects and people, it’s important to look out for the following:
- Signage indicating hazardous areas and materials
- Emergency exits and procedures in case of a fire, flood, or earthquake
- Unsecure railings
- Items blocking hallways and passageways
- Avoid shortcuts
If you’re running behind schedule, you may be tempted to skip a few steps to catch up. But those steps could be the difference between safety and an injury. Don’t take shortcuts and always follow instructions for using tools and machinery.
3 Key Milestones in Worker Safety
The Industrial Revolution brought many changes to the workplace that accelerated production but also increased the risk of injury and even death. Dangerous work conditions led to the creation of workplace safety laws that continue to shape working conditions today.
- Employers Liability Law
The Federal Employers Liability Act (FELA) was passed in 1908 to protect railroad workers supporting the rapid expansion of the nation’s railway network. Under the law, employers could be held liable for worker injuries and death on the job. Employers were also required to compensate injured workers and their family members. However, employees were required to prove employer negligence to receive benefits.
- Workers’ Compensation
Workers’ compensation insurance was created in Germany in 1870 and spread across Europe in the late 19th century. The first comprehensive workers’ compensation law in the US was passed in Wisconsin in 1911. In 1948, workers’ compensation insurance was available in all states. The workers’ compensation system gave injured workers access to medical care and wage replacement benefits.
Today, workers’ compensation insurance is regulated at the state level and most employers are required to provide coverage.
- Safety Agencies
Throughout the 20th century, many government agencies and non-governmental organizations were established to monitor workplace safety and enforce compliance. The three main safety agencies in operation today are:
- The US Department of Labor (DOL)
The DOL offers resources and training for job seekers and retirees and sets wage standards. Its mission is “To foster, promote, and develop the welfare of the wage earners, job seekers, and retirees of the United States; improve working conditions; advance opportunities for profitable employment; and assure work-related benefits and rights.”
DOL oversees numerous offices, agencies, and program areas to fulfill its mission.
- The Occupational Safety and Health Administration (OSHA)
Part of the DOL, OSHA was established in the 1970s to enforce the Occupational Safety and Health Act. OSHA sets workplace safety standards and enforces policies to keep employees safe and healthy. The administration also provides training, outreach, education, and signage to employers.
- The National Safety Council (NSC)
This non-governmental, non-profit, member-driven organization promotes health and safety by providing safety training, conducting research, and offering tools to mitigate risk. NSC also engages in government advocacy across national and local levels to drive awareness and create policies that support workplace safety.
How to Reduce Workplace Injuries During The Holiday Season
The holiday season is the busiest part of the year, which means the risk of worker injuries is higher as well. To keep the season merry and injury-free, here are a few tips every business should follow.
Mind the decorations
Injuries associated with overexertion and same-level falls are the leading cause of workers’ compensation payouts each year. Actions like lifting, holding, pushing, pulling, throwing or carrying objects can lead to expensive injuries. To prevent injury, be sure to:
- Place trees away from fireplaces, radiators, and other sources of heat.
- Ensure the platform is stable before placing a tree.
- Ensure artificial trees are fire resistant.
- Before installing lights, check for fraying, bare spots, and gaps in the wiring insulation.
- When hanging or taking down decorations, use a step stool or ladder.
- Secure and cover wires on the floor.
- Provide extra breaks to employees setting up decorations.
- Train employees to use proper technique when bending and reaching.
- Restrict public access to areas where employees are installing decorations.
Be careful with holiday parties
A holiday party can be a time for employees to let loose and celebrate the season. It can also open up workers to injuries caused by inebriation and reckless behavior. To avoid alcohol-related injuries, only serve non-alcoholic beverages. But if you decide to serve alcoholic drinks, be sure to take the following steps:
- Instruct managers to lead by example during the party
- Designate a sober driver or ensure workers take a ride share or taxi home
- Avoid hard liquor and fruity drinks
- Host the party early in the day to discourage heavy drinking
- Serve plenty of food to minimize the effects of alcohol
- Offer activities to give workers something else to do, besides drinking
- Host the party at a restaurant where bartenders are trained to know when to stop serving a customer
- Invite employees’ family members (because people are less likely to drink heavily around children and spouses)
- Implement a voucher system to limit the number of drinks an employee can receive for free
Worker safety should be a priority for every employer year round, but especially during the holiday season. A great time doesn’t have to end in tragedy if the necessary precautions are taken.
Workers’ Compensation Laws Governing Longshore and Harbor Workers
Longshore and harbor workers receive special protection under the Longshore and Harbor Workers’ Compensation Act (LHWCA), which provides financial compensation, medical care, and vocational rehabilitation services to individuals disabled from job injuries sustained in the navigable waters of the US or in adjoining areas. Under the LHWCA, dependents of fatally injured workers also receive benefits. These benefits are paid by a private insurance company or the self-insured employer.
LHWCA Coverage
The LHWCA covers longshore workers, shipbuilders, ship-repairers, and harbor construction workers. To qualify for compensation, workers must have sustained injuries in the navigable waters of the US or in the adjoining areas, including wharves, terminals, docks, piers, and loading and unloading areas. Non-maritime employees may also receive compensation if injured while performing work on navigable water.
LHWCA Exclusions
The following individuals are not covered by the LHWCA:
- Seamen (which are masters or members of a crew of any vessel)
- Employees of the US government or of any state or foreign government
- Employees whose injuries were caused solely by their intoxication
- Employees injured due to their own willful intention to harm themselves or others
The LHWCA also excludes individuals covered by a state workers’ compensation law:
- Office clerical, secretarial, security, or data processing workers
- Individuals employed by a recreational operation, restaurant, museum, club, camp, or retail outlet
- Marina workers not engaged in construction, replacement or expansion of a marina
- Individuals employed by transporters, suppliers, or vendors who are doing temporary work on the premises of a maritime employer and aren’t doing work typically performed by the employer’s workers
- Aquaculture workers
- Workers building a recreational vessel less than 65 feet long, repairing a recreational vessel, or dismantling any part of a recreational vessel during repair
- Small vessel workers, under certain conditions
How To Report An Injury
The first step is to notify the supervisor or manager of the injury as soon as possible. Workers who need medical attention should also seek treatment immediately. Workers can select a physician to treat their injuries.
The Form LS-1, Request for Examination and/or Treatment, should also be completed by the worker for medical treatment authorization. In emergency cases, the worker may request authorization after obtaining emergency care.
How To Build a Successful California Workers’ Compensation Case
If you’ve been injured on the job, taking the right steps is key to building a successful workers’ compensation case. An experienced workers comp attorney will guide you through the process and ensure you receive the benefits you deserve.
- Understand the basics of workers’ compensation.
In California, a workers’ compensation case primarily addresses physical injuries. Workers may receive benefits for mental and emotional injuries, but these cases (referred to as stress claims) are more difficult to prove and must meet stringent requirements. To receive benefits for a psychiatric injury, workers must:
- Have a mental disorder that has been diagnosed under acceptable procedures
- Have required medical treatment or experienced disability
- Have worked for the employer for at least six months
- Prove that actual events of employment were the predominant cause of psychiatric injury
- Obtain prompt medical treatment.
Workers with physical injuries must seek medical care right away. Neglecting early treatment may give insurance companies a reason to deny or fight a claim. Once workers have reported the injury to their employer, they may receive $10,000 worth of medical care regardless of whether their claim is approved or denied.
- Don’t skip medical appointments.
Claimants must show their commitment to receiving medical treatment and attend every medical appointment. Gaps in treatment will give the insurance company a reason to doubt the validity of your claim and the extent of your injuries. A consistent record of medical appointments will help build a solid workers’ compensation case.
- Set realistic expectations for case value.
An experienced workers’ compensation attorney will determine the value of your case and help you set realistic expectations. It’s important to understand that the California Workers’ Compensation system doesn’t give workers the full range of benefits available in the civil court system. Injured workers won’t receive compensation for pain and suffering or compensation for punitive damages.
- Choose the right attorney.
An attorney specializing in workers’ compensation will know the ins and outs of the legal system and help you secure the compensation you deserve. Before hiring an attorney, read customer reviews, schedule a consultation, and find out who will be handling your case. If you have any questions about your workers’ comp case, don’t hesitate to reach out to Thomas F. Martin, PLC.
The Top 7 Causes of Workplace Fall Injuries
An experienced work injury attorney has worked on many cases involving falls. Though there are numerous causes of workplace falls, the injuries workers sustain from a fall inevitably require medical attention and time off from work.
Recognizing the risk factors for falls in the workplace can help prevent these accidents and keep workers safe. Here are the top seven causes of falls in the workplace.
- Uneven floors
Uneven floors may be slightly angled, without any warning signs posted. In other cases, the sidewalk outside of a building may have sunk into the ground or risen up, creating cracks that could lead to an accident. Cracked tile floors with missing pieces could also lead to a fall.
- Loose cords
Loose cords from equipment and machinery pose a trip hazard that could lead to serious injuries affecting the back, hip, pelvis, spinal cord, and bones. Workers may suffer concussions, fractures, and even brain damage from just a few loose cords.
- Wet floors
Floors that were recently cleaned should have a caution sign posted, warning workers to watch their step. On the other hand, oil or other liquid spilled onto the floor should be cleaned as soon as possible to prevent falls.
- Insufficient lighting
Poor lighting makes it difficult to see steps, uneven flooring, and obstacles on the floor, increasing the risk of a fall. Employers need to make sure lighting is working properly in all work areas and install additional lighting where necessary.
- Obstructions
One common cause of falls is obstruction. Work injury attorneys often handle cases in which workers tripped over boxes, tools, and various containers.
- Rugs
Old, small rugs aren’t very sturdy and likely to become bunched up and create a tripping hazard. Workers can fall in bathrooms, storage closets, and hallways, and sustain injuries that require medical treatment.
- Improper footwear
Restaurants, stores, and manufacturing buildings are likely to have wet floors that increase the risk of a fall. Employers should ensure every worker is wearing slip-resistant footwear in these environments.
Choosing a Work Injury Attorney
Not every fall is preventable and in some cases workers can sustain serious injuries. Hiring the right work injury attorney is key to receiving the necessary benefits and compensation. Call Thomas F. Martin today for a legal consultation.
What to Expect From a Psychiatric Workers’ Comp Claim in CA
When we think of workers’ comp injuries, we generally think of physical injuries like broken bones, tissue damage, burns, and lacerations. But workers’ compensation also includes psychiatric injury, which is a mental disorder determined to be at least 50% caused by the workplace.
How to claim a psychiatric injury.
To obtain compensation for a psychiatric injury, an employee must:
- Show employment for six months or longer
- Prove that work activities or the work environment were greater than 50% of the cause of psychiatric injury
- Prove the injury was not a consequence of physical injury
If the psychiatric injury was caused by a violent act, then the employee must show that 35-40% was caused by work. In addition, the six-month requirement doesn’t apply to injuries caused by a sudden and extraordinary event.
Can physical and psychological injuries be combined in a claim?
A psychological injury cannot be caused by a physical work injury. An injured employee can only add a psychological claim to the original injury if it was due to a violent crime or a catastrophic injury such as paralysis, severe burn, amputation, or severe head injury.
What is the difference between an injury and a permanent disability?
If the worker has not sustained a psychiatric work injury, then they will not receive any medical treatment, temporary disability, or permanent disability. If a physician does identify a psychiatric injury in a worker, then the extent of disability and evaluation of non-work-related factors will be determined on a separate basis.
How a psychiatric claim is rated in CA workers’ comp.
In California, a psychiatric work injury is rated using the Global Assessment of Function (GAF) scale, which is then converted to a percentage and adjusted up or down using the Permanent Disability Rating Scale (PDRS). A GAF rating below 70 is considered a permanent disability.
What to expect during a psychiatric injury claims process.
To determine a worker’s eligibility for compensation, the insurance company will ask questions about the workers’ relationship with friends and family, medical conditions, sex life, past abuse, and trauma. An injured worker should decide if filing a psychiatric claim is worth answering questions on such personal matters.
Why CA Workers’ Comp Investigation Timeline May Change
The length of time it takes to investigate a workers’ compensation claim varies depending on the type of injury reported, the circumstances surrounding the accident, witness availability, the extent of the medical conditions, the availability of documentation, and the cooperation and availability of all parties involved.
California bill SB 1127 would reduce the investigation period for claims in which workers have a presumption of compensability to 75 days from the employer notification of the injury. In other claims, the investigation period would remain at 90 days.
Challenges With Workers’ Comp Investigations
The California Workers’ Compensation Institute (CWCI) conducted a study that found potential problems associated with reducing claim investigation time frames; these include:
- Litigated and denied claims require significantly more time to gather reports and documentation from outside sources. Only 49.2% of litigated claims that are eventually denied have a compensability decision at 75 days.
- Employers are currently liable for up to $10,000 of medical treatment for a claimed injury during the investigation period, regardless of the insurance company’s final decision. Reducing the time frame would reduce the amount of time workers whose claims are eventually denied have to receive $10,000 worth of medical care.
How Workers’ Comp Investigations Proceed
A workers’ comp investigation looks at video surveillance, online social media channels, interviews, and medical reports to determine whether the claim should be approved or denied. The insurance company’s claims team is checking to see if the injury is fake or exaggerated if the injury is job-related, and if the employee is still working.
Investigators will watch employees coming and going from home and doctor’s offices. In addition, they will review the injured employee’s online posts, tagged photos, status updates, and other online activities. Investigators will also interview employees over the phone or in person to see if the injury is valid and work-related. Workers’ comp claims teams may also interview the injured employee’s relatives, close friends, coworkers, and neighbors to learn more about the employee and identify potential fraud.
Legitimately injured workers don’t need to worry about the claims investigations process. Hiring an experienced work injury lawyer in Orange County, CA will help ensure they have a solid case and receive the compensation they deserve. Call Thomas F. Martin, PLC today to schedule a consultation.
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