How To File an Arizona Workers’ Compensation Claim: Part I

 

No one needs the complications and stress of being injured on the job.  However work related injuries are far too common.   Accidents, repetitive motions, over exertion, illnesses and even stress regularly cause injuries in the workplace.   Most people including lawyers outside the area of workers’ compensation have little experience with the Arizona workers’ compensation system.  Sustaining a physical or mental injury on the job that affects your ability to work can be financially and emotionally devastating to those fail to understand the Arizona workers’ compensation laws and procedures. What should you do if you are injured in the course of your work?  Below is a basic guide to help you understand and prepare for an on-the-job injury claim under the Arizona workers’ comp system.  To begin, there are five basic steps to follow to begin your claim properly:

 

  • In an emergency, seek immediate medical attention as you would in any emergency situation.
  • Inform your employer through your boss or supervisor that you have been injured first in non-emergency situations.
  • Get to a doctor as soon as possible.
  • Make sure the claim has been filed.
  • Inform your employer of any limitations the doctor has placed on your work activity.
  • Seek advice from an Arizona Workers’ Compensation attorney if you have any doubts.

Once your claim has been filed, you should receive a letter from the Industrial Commission of Arizona, which is the state agency charged with adjudicating and administering the Arizona workers’ compensation system.  The letter will indicate that the workers’ compensation insurance carrier for your employer has been contacted about your injury.  The insurance carrier has 21 days by law to decide to accept or deny your claim.  If you do not receive the Industrial Commission letter, response from the insurance carrier or your claim is denied by the insurance carrier, contact our office immediately as your time is very limited to protest the decision.  If your claim is accepted, there are two basic types of benefits paid under workers’ compensation: monetary and medical.

 

Medical Benefits:

Workers’ compensation insurance pays 100% of all your medical bills.  You should NEVER receive a bill from a medical provider for any service or medication necessary to treat your work related injury.  If you do receive a bill, contact our office.  You are eligible to receive “active” medical benefits until the doctor believes your condition cannot improve any further, or is “stable.”  That does not necessarily mean that you are physically 100%.  It means the doctor has run out of treatment options.  If you have a permanent disability as a result of your injury, you may be eligible for both long term medical and monetary benefits for certain types of injuries.

 

Monetary Benefits:

You can receive up 66 2/3% of your average monthly wage while your doctor says you are unable to work.  The average monthly wage is not necessarily your salary.  It is typically the wage you earn 30 days before you were hurt.  So, if you had a light month of work before, it wouldn’t be the average of your last year’s earnings.  In addition, depending upon your date of injury, the average monthly wage has a cap.  If you earn more than the cap in your salary, you will not receive 2/3 of your salary but only 2/3 of the maximum average monthly wage.  The average monthly wage can be a complicated calculation.  The insurance carrier should issue a “notice” shortly after the acceptance of your claim indicating what they believe is your “average monthly wage.”  If the insurance estimates your earnings to be too low, it could significantly affect the amount of money you will receive throughout your entire case, which could seriously impact long term monetary benefits.  That could mean thousands of dollars lost due to failure to protest the insurance carrier’s calculations.  Getting the insurance to accept a higher wage may require court action.  Do not hesitate to contact our office as soon as you receive this notice.

 

Monetary benefits are paid every 14 days while you are completely unable to work.  However if your doctor allows you to work but with some type of restriction(s) on your work activity, the insurance will send payment every 30 days, and only after you have filled out an monthly status request form.  Always keep your employer informed of your work status.  If you can work in a limited capacity but your employer will not offer you work, you may be required to look for limited work.  Once your doctor releases you to work without restrictions or closes your case, regardless of whether or not you are working, you will no longer be eligible for payments to cover lost salary.

 

Your medical benefits continue until a doctor closes your case, and your monetary benefits continue until any of the following occur: you are earning your full salary, your doctor releases you to full work status or closes your case.  Sometimes the insurance company will hire a doctor who’s opinion contradicts your doctor’s opinion.  If one doctor believes that your condition is stable and that your case can be closed, the insurance carrier will close your case.  However if you and your doctor disagree, you can protest.  Contact our office immediately if your case is closed by a doctor hired by the insurance company, as your time to fight the decision is limited.


How to File Your Claim: Part II

Once your doctor closes your case (at the point where your condition is no longer improving) they should assess whether or not you have made a full recovery.  If you have fully recovered, you will not be eligible for any type of monetary award at the closure of your case.  However if not, the doctor should “rate” your disability in the form of a percentage.  Based on this number, you may be eligible for one of two types of post-closure monetary benefits called “awards”. Your doctor can also recommend post-closure medical benefits as well:

“Scheduled” Award:  This type of award is usually the result of a permanent injury to the extremities, eye or ear.  The percentage of disability given by your doctor is plugged into a formula used to calculate this type of award.  These awards are only paid out over a set number of months indicated in the formula, and then end.  Pay careful attention to these awards, because they are commonly miscalculated in favor of the insurance carrier .  You may also be eligible to receive vocational training from the state if you are unable to continue your prior job.

 

“Unscheduled” Award:  This type of award is usually the result of a permanent injury to the back, neck, shoulders, or two “scheduled” injuries.  The existence of a previous workers’ compensation claim, even in another state could make you eligible for this type of award.  Unlike a “scheduled” award, this award is based on your general reduction in ability to earn, not just your percentage of disability.  That means that it is possible to receive nothing if the insurance makes a case that you have no diminished earning ability, even with a disability!  Insurance carriers will often contract doctors and labor market experts to prove you have no diminished earning capacity.  This type of benefit has to be reaffirmed every year, can go up or down, and can be fervently contested by the insurance carrier.   The assistance of an can often be the difference between receiving nothing and significant monthly award.

 

Supportive Medical Benefits: Even if your doctor has to close your case because your condition cannot be improved, your doctor could recommend some continuing basic medical benefits to maintain your condition.  Medications, office visits, therapy and braces are common types of post-closure medical benefits.  Your doctor can indicate the need for such treatment in his final evaluation before closing your case.  The insurance carrier then has to issue a “notice” explaining what benefits you will receive.  Usually the doctor recommends that benefits be issued for a year, and may be renewed at the end of this period.  However if you fail to use these benefits, you will lose them!

Sometime a case has to be reopened several months or years after it is closed.  While certain treatments can be performed to maintain your condition while your case is closed, more serious treatments like surgery require your case to be reopened.  The possible need to reopen a case is an excellent reason to take advantage of supportive medical benefits.  Reopening a case requires medical proof, usually in the form of a doctor’s report.  Reopenings are often denied, and your time to fight the denial is limited.  If your case is successfully reopened, you will be eligible for the same benefits as a new case.

The Arizona workers’ compensation system is a serious legal process.  As any legal process, you have rights, as well as some responsibilities.  Your knowledge of your rights, as well as your compliance with legal your responsibilities are essential to the survival or your Arizona workers’ compensation claim.  There are three basic principles that will help you properly exercise your rights and get you what you are entitled to:

  1. NEVER Make Assumptions.  Never assume your boss or manager knows that you are hurt unless you tell them.  Never assume that your doctors are aware of every part of your injury unless you tell them.  And above all, never assume you know the law unless you have been informed by an Arizona workers’ compensation attorney that specializes in workers’ compensation.  NEVER assume anything.
  2. Don’t Let Time Pass By!  Do not wait to tell your boss or supervisor that you are hurt.  Do not wait to file your claim.  Do not wait to go to a doctor if you believe you are injured.  Do not hesitate to contact an attorney with questions.  Acting quickly is one of the best ways to ensure that the process works, because time is one of the most valuable resources in law and medicine.

Listen Carefully To Advice.  This process will usually try hard to be frustrating and insulting, but effectively utilizing competent, professional advice from your doctor or attorney is often essential to the general process, and certainly indispensable in the most complex medical and legal situations.  Being injured and out of work can be a lonely and freighting place to be, but if you tap into the knowledge and experience of professionals that have seen many situations like yours, it’s not an unfamiliar place.  Don’t let a giant insurance company intimidate you.  You have access to an attorney with more knowledge and experience than any insurance adjuster.


How to File Your Claim Part III

Apply these general principles to your Arizona Workers’ comp claim, and you should be in a better position to go through the claim as smoothly as possible.  However there are plenty of big and little things that can go wrong with a claim, as well as plenty of details and responsibilities to watch out for.  What if your claim is denied?  What should you do if you aren’t getting along with your doctor?  What if you never Check out the Frequently Asked Questions (F.A.Q.) section for more details on specific issues.

Those are the basics of the Arizona workers’ compensation system.  It can be a confusing and impersonal process, but contact our office if you have any questions.  Don’t let your employer ignore your claim, don’t let the insurance bully you and don’t even let well-meaning friends and coworkers confuse you with misinformed advice.  Contact the law offices of Robert E. Wisniewski today to begin working with the most experienced and knowledgeable Arizona workers’ compensation specialists.

 

Frequently Asked Questions:

Q: My boss hasn’t or won’t file a claim.  What do I do?

A: Doctors will often file the claim if they know your injury should be under workers’ compensation insurance.  However if your doctor fails to file the claim, you can file the claim yourself by filling out “worker’s report of injury” form that you can get from the Industrial Commission of Arizona or our office.

 

Q: I don’t get along well with my doctor, and I don’t think I’m getting good treatment.  Can I change doctors?

A: Often, yes, if your employer is not self-insured.  You have to apply to and be approved by the Industrial Commission to change to a new doctor.  Frequently the relationship between a doctor and patient can break down.  We can recommend a doctor that has a good professional relationship with our office in case you experience such an issue.

 

Q: My claim was denied.  Now what?

A:  You have to file a “protest” with Industrial Commission of Arizona.  If you don’t have an attorney, don’t wait!  You only have 90 days to request a hearing date with a judge to protest the denial, because a hearing is the ONLY way to guarantee yourself a chance to get the insurance carrier’s decision reversed.  If you fail to file a protest in time, your claim is OVER.  It is highly recommended that you contact an attorney if your claim is denied.  Your attorney can file a protest for you, and may be able to negotiate the acceptance of your claim without going to court.  Most importantly, your attorney knows which particular facts prompt insurance companies into action and compel judges to rule in your favor.

 

Q: I have been out of work for more than a month.   Why haven’t I received any money?

A: There could be several reasons why you have not received a check.  The claim may have been denied, filed late, never filed or accepted without notification as a “no time lost” claim.  You may be on “light duty” status per your doctor, but have not filled out the insurance carrier’s monthly status form.  Sometimes the carrier lacks wage information to calculate benefits.  It is also not uncommon for insurance carriers to act slowly for various reasons, often blaming doctors and employers for failing to send requested information.  A good attorney will figure out what the problem is and keep the pressure on the insurance company to issue timely benefits.

 

Q:  Can I be fired while on workers’ compensation?  What will happen to my claim?

A:  In Arizona, injured status does not protect your job, even if your employer is at fault for your injury.  Fault generally does not matter in the system, and workers’ compensation does not alter your employer’s right to fire employees for almost any reason.  However your employer cannot prevent you from filing a claim by firing you.  Sometimes employees are even forced to quit their jobs because they become permanently unable to perform the job.  Regardless of your current relationship to your employer, you are entitled to file a claim.  Remember, your claim is processed and paid by the insurance carrier, not your employer.

 

Q:  Can I sue my employer?

A:  The answer is usually no.  Employers may often be at fault for injuries, but employees eligible for workers’ compensation are barred from filing lawsuits against their employers.  However the trade off in this “no fault” system is that employees can collect benefits even when the employee is at fault for their own injury.  The most notable exception to this is when another company or “third party” is responsible for your injury.  In this case you can collect benefits under your employer’s workers’ compensation insurance to treat your injury while your third party lawsuit is pending.  However the insurance carrier will have a lien against all benefits paid in your claim.

 

Q: Will the insurance carrier reimburse my travel millage?

A: If you have to travel more than 35 miles to see a doctor because there are no specialists near you, you can be reimbursed.

 

Q: I need to move out of state while I’m in the middle of my case.  Can I move without losing my benefits?

A:  Yes.  You need to file a change of address, as well as find a new doctor in near your new area.  Your attorney may be able to help find a new doctor if finding one proves difficult.  However you will have to make the trip back to Arizona if there is a need for a hearing.

 

Q: The insurance is demanding that I go to medical exam with some doctor I’ve never seen.  Do I have to go?

A: Insurance carriers will often use these exams known as “Independent medical exams” to build evidence for various reasons or to double check your doctor’s assessment.  An unfavorable opinion from any doctor can be used to limit your benefits, close your case or deny it completely. It is essential to have the best medical and legal specialists on your side, in case you have to fight for you right to treatment and benefits.

 

Q: I was hired and usually work in Arizona, but I was injured in another state.  Where do I file my claim?

A: You can file the claim in either the state where you were hired, or the state in which you were injured.  If you live and work mostly in Arizona, it may be the easiest place to file your claim.  Since workers’ compensation laws vary from state to state, your lawyer and court hearings will both be in the state in which the claim is filed.