WHEN WORKER’S COMP DOESN’T PAY
This Post covers 2 areas: when Worker’s Comp doesn’t pay for 1)medical treatment or 2) temporary disability.
Worker’s Comp Doesn’t Pay Because it Doesn’t Know There is a Claim
Remember, the worker’s comp insurer pays the benefits, not the employer. Some employer’s have self insurance, but even then, a claims administrator authorizes benefit payments. So, first, the insurance company needs to know you have made a claim.
Supervisors must make a “Report of Injury” when they become aware of a workplace injury. You must report your injury to the super. Just because a co-worker was with you when you were hurt, doesn’t mean the super got notice.
Some employers fear their insurance rates will rise if they report an injury. Your super may discourage you from reporting your injury. Even worse, the super may intentionally withhold reporting your injury. Either way, if the insurance doesn’t know, it will not pay.
Contact a lawyer when you cannot get cooperation from work. We bypass the insurer, and file the claim directly with the Worker’s Comp Division in Jefferson City, and they will in turn contact your employer’s insurance company.
Note: Worker’s Comp insurance is usually different from your employee health insurance. If your health insurance is paying for the treatment, this does not mean your claim has been accepted by worker’s comp insurance. Usually health insurance won’t pay when you tell the doctor you got hurt at work. They tell you to turn your claim into the worker’s comp insurance. Then, you turn your bills into the worker’s comp insurance, and they deny payment because the work comp doctor doesn’t agree that work caused the injury. This is a Catch-22. I tell you how we handle that situation in this post.
Worker’s Comp Doesn’t Pay because it doesn’t believe your injury is caused by work.
There a couple of major reasons worker’s comp doesn’t cover your work injury:
- The medical doctor who treated your injuries does not write in the notes that your injury is caused by work. You must report that the injury happened while working. Many people only report their symptoms, such as “my shoulder hurts”. You have to tell the doc more specifically what caused the pain. Example: “I work on a line at the hog farm trimming the picnic (pig) as it goes by. My job requires me to constantly reach above my shoulder. I felt a pop in my shoulder yesterday at work.”
- The doctor doesn’t believe that the workplace incident caused the injury. For example, if you have a heart attack at work, it is not clear that your work activity causes heart attacks. Or, you complain of new knee pain but you had surgery on the same knee 5 years ago. The doctor calls it a pre-existing injury, so you are denied benefits.
Note 1: Although work comp chooses your doctor, you are entitled to a second opinion. However, you have to pay for it. Clink this link to read “the Missouri Department of Labor article, “Why can’t I choose my own doctor?”
Note 2: When you are headed to the emergency room, work comp insurance does not choose the doctor that treats you. They will pay that bill. This is a common situation for over-the-road truckers who could be injured outside the State of Missouri. See my post Worker’s Comp Truck Injuries in Missouri.
DISABILITY WAGES: TTD
Wages are only available when you miss 3 consecutive days of work.
When a worker is injured and off of work for at least 3 consecutive days, Worker’s Comp pays “Temporary Total Disability”. We call this “TTD”. The doctor must authorize your time off, or it doesn’t count. In general, TTD payments equal only 2/3 of a normal paycheck. There is a maximum limit of the TTD check. The limit changes every year. So, for a higher paying job, the TTD check may pay less than 2/3 of your normal paycheck.
If you are not off of work for 3 consecutive days, you do not receive TTD payments.
When the Worker’s Comp doctor releases you to full duty without restrictions, TTD payments stop. But, when you cannot return to work because of pain, what then?
Hardship: The Cure for when Worker’s Comp Doesn’t Pay
The employer’s insurer controls payment of medical bills and TTD benefits. Missouri law allows us to file a “Hardship” Motion, so that a Judge will decide if worker’s comp should pay. We will need to get a doctor’s opinion that the workplace injury is the “prevailing factor”. Otherwise, we cannot win the Hardship Motion. If we have a doctor’s opinion that work was the prevailing factor of the injury, causing the hardship, and the employer’s doctor has the opposite opinion, a judge will have to decide.
Legalese lesson of the day: “Prevailing Factor”
Missouri law requires the incident at work to be the “prevailing factor” before worker’s comp benefits apply. This means that in a doctor’s opinion, more likely than not, what happened at work caused your current injury. Before the latest round of tort reform passed by the Missouri legislature, almost any injury at work qualified for work comp. Today, the incident must be more likely than not, what caused the injury. Put another way, 51% of the cause.
We file a Motion for Hardship Setting if the actions, or inaction, of the employer’s worker’s comp insurer cause the injured worker undue hardship. This is usually in one of 2 areas: denying payment for medical treatment, or terminating TTD payments. In either case, we need a medical opinion stating you either need more treatment, or cannot yet return to work. The independent doctor must state the opinion that 1. you need treatment or disability payments because the workplace injury was the “prevailing factor” it their cause, and 2. You need the treatment or disability payments. Many doctors do not have experience in worker’s comp cases and do not understand the significance of actually writing the specific words “prevailing factor”. I call the doctor and explain this. I also know doctors around Missouri who are experienced in worker’s comp cases.
The Hardship Setting may take place within 10 days, but usually takes longer, depending on the court location. If we win the Hardship Motion, your employer may have to pay attorney fees. This can also be an incentive for a voluntary payment by the employer for the time being. If you were wrongfully denied TTD, the judge may order backpay as well.
When Worker’s Comp doesn’t pay, there is still a way to make them pay. You need a lawyer who understands the nuances of the laws. See my post on Work Comp FAQ