When you have filed a workers’ compensation claim as an injured worker, stay on top of things so you can make sure things are properly progressing. It is not always going to be easy to do because of your physical injuries, but your workers compensation benefits may depend on it.
Medical costs, wage replacement benefits, future medical bills, and lost wages, are all part of what an experienced workers compensation attorney uses to obtain the maximum payout possible.
Injured workers need help understanding workers compensation law and your right to claim status.
Chances are that you are receiving medical treatment, and you may also be in a significant amount of pain. Even though your employer and insurance company have their obligations about timing, it is up to you to keep up-to-date and stay informed of the status of your claim.
Consult a workers comp attorney to help you understand the complex laws.
Here is what you can do to track your workers’ comp claim:
You may have already filed your workers’ compensation claim using Form DWC-1.
You have submitted this form to your employer, who forwarded it to the insurance company according to their legal obligations. At that point, the insurance company has received the employer’s accident report and your income statement.
They will seek a release to obtain your relevant medical records, so they can verify that you have suffered a work-related injury.
The insurance company cannot go on a fishing expedition for all your medical records. They need to restrict their search to those relevant to your injury. Reach out to a workers compensation lawyer.
They might request that you release your entire medical history, but you do not have to – and should not – agree to this.
Having your historical records allows them to search for any pre-existing conditions they can blame your injury on.
For the best chance of a smooth process, always discuss your workers’ compensation lawyer. Seek legal help immediately if you check the status of your claim and learn the insurance company issued a denial or is causing unreasonable delays.
You May Have Your Answer Within Two Weeks of Filing the Claim
If your case is relatively straightforward, you can hope to hear something back from the insurance company quickly. Workers’ compensation claims are unlike personal injury claims, where the insurance company needs to investigate the fault and is trying to wear you down. Although workers’ compensation insurance companies can be complex, they also know they are under strict time constraints based on California law.
Why the Insurance Company May Not Respond Immediately to Your Claim
Still, there may be several factors that keep the insurance company from responding to you immediately, including:
- They have a high caseload.
- They do not have enough staff to review your claims promptly.
- Your claim may be missing some essential information.
- The insurance company may need to investigate further the factual circumstances surrounding your injury.
- The insurance company needs to review your medical file to confirm that you have suffered an injury and your medical condition stems from your job.
Always Keep Track of Your Claim
You should stay on top of your claim once you file it. Even though the insurance company must respond to your claim within a specific time under California law, it can help your peace of mind to know that the insurance company has received your claim and is processing it.
Calling to check on your claim may not prompt the insurance company to act any quicker, but it can help your mental state to have a conversation and learn where things stand.
If you do call the insurance company, you should have key details, such as:
- Your name
- Your employer
- The date of your injury
- The type of injury you suffered
- Any claim number they assigned to you
Under California law, the insurance company should have confirmed receipt of your claim within 14 days of the filing. They may have assigned you a case reference number that you should keep handy throughout the process. Depending on the strength of your claim, the insurance company may even decide to accept your claim within the first 14 days.
If the insurance company cannot decide within this time, they need to give you notice and explain why they are not making an immediate decision. Then, they can extend the time to decide to 90 days. Then, you may want more information about when you receive an answer.
The Insurance Company May Not Say Anything to You When Processing Your Claim
In many cases, other than receiving various requests for the release of records, you may not receive any communications from the insurance company between the acknowledgment of receipt of your claim and their ultimate decision. The insurance company does not feel as if they owe you any service.
You are a claimant, and your claim costs you money. If anything, your employer is their client because they pay insurance premiums, although the insurance company may not provide a high level of service to anyone.
Be Very Wary When You Get a Request for a Further Medical Evaluation
One communication you may receive is a request to attend a Panel Qualified Medical Evaluation (PQME) in the first 90 days after the accident. You must attend this evaluation or risk the denial of your claim. If the adjuster asks you to attend a PQME, it is a sign that the insurance company may have doubts about your claim.
If you do not already have a workers’ compensation attorney, hire one. You may need to battle the insurance company to get the benefits that you deserve. You should not attend a PQME without at least speaking to an attorney. Everything you do and say at a PQME can be used as evidence against you if you file an appeal of a denial.
The Insurance Company May Take All the Time that it Needs
However, you should remember that the insurance company has 90 days to review your claim. Your claim will be automatically accepted if they do not accept it within that time or respond.
The insurance company may not want to give you any information besides that it is processing your claim. As much as you want to know the status, the insurance company may not want to tell you. Thus, you may just need patience.
While waiting for the insurer to process and accept your claim, you can receive coverage for emergency medical care relating to your injury and up to $10,000 in medical care (regardless of whether your claim is eventually successful). Still, $10,000 is not a lot these days regarding medical benefits.
Be Careful When Talking to the Insurance Company
If you have any conversation with the insurance company, you should keep it limited to just discussing the status and when you may receive an answer about whether your claim is successful. The insurance company will listen to everything you say and take notes if you say something they can use against you. Insurance companies can take even a seemingly innocent statement out of context and use it as a justification to deny your claim.
Why You May Want to Hire a Lawyer for Your Workers’ Compensation Claim
Even better, you should have an attorney on your side who can have any necessary conversation with the insurance company. Your attorney knows what to say and what not to say, and they can relieve the stress of dealing with the insurance company. Your attorney will stay on top of dates and deadlines so that you can worry about your health. Many people find it well worth hiring an attorney at the beginning of the process, so they are prepared and can make the right decisions.
You May Need to Appeal the Denial of a Claim
There comes a point when you have done everything you can, and you will need to wait for your claim to be approved or denied. You must be ready because you must act quickly to appeal any denial of your claim.
The insurance company may deny your claim because:
- They do believe that you suffered an injury
- They believe that your injury was not related to your job (or the job insured by that particular carrier)
- They think that your injuries were the cause of your intentional actions
- Your claim was missing certain essential information
- Your injury is a pre-existing condition, not something that happened on the job
The insurance company must explain its reasons for denying your claim in writing. At that point, you have the legal option to appeal a denial. First, your attorney may contact the insurance company to discuss the denial. It may be that your claim was missing critical information, or there was a misunderstanding that you or your lawyer can clear up with a phone call.
The insurance company may not want to go through the expense of a trial (they must pay their defense attorneys) if there is an easy fix to the problems that caused them to deny your claim. They may want to reserve a trial for a more fundamental dispute that involves your eligibility for benefits in the first place.
Insurance companies sometimes deny claims to put the onus on you to appeal. They may think you will go away if you fight for what you deserve. When you hire an experienced lawyer, you do not simply have to go away. You can fight back within the rights allowed to you by California law.
You Need to Be Ready to Appeal Quickly
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Under California law, you have one year from the date the claims administrator or insurance company denies your claim to file an appeal. Even if you think you have some time, you do not want to wait too long to file your appeal. You may not receive money or medical care coverage in the meantime. In addition, you do not want the stress of the situation hanging over your head for too long.
Workers’ compensation appeals happen on a relatively expedited basis, so you will not have to wait long for the final answer in your case. Either way, you have the right to an objective review from a neutral who does not have the same financial interests as the insurance company.
If you have filed a workers’ compensation appeal, California maintains a system that allows you to check on the status of your appeal. You will need to log onto the Electronic Adjudication Management System and enter certain required information to check the record in your case. You can learn more about deadlines and milestones in your case from the online system, including whether an attorney has made a filing with the court.
When you have hired a workers’ compensation attorney, you will not have to deal with the details of your claim personally. You will not have to worry about contacting the insurance company, waiting on hold, and providing them with information.
You can put details like these in the hands of your workers’ compensation attorney. In addition, your attorney can help you complete the claim and deal with everything else. You only need to see the doctor and follow up with your medical treatment. You will also need to make decisions in your case after you have consulted with your attorney.
For many people, it is worth the investment to hire a lawyer. You do not need to spend money out of your pocket. Your lawyer is paid a percentage of your financial recovery based on the time they have spent on your case. You do not need to pay your lawyer for their time if you do not receive benefits. You will get a lot of peace of mind during a difficult time when you do not want to have to worry about the legal process.
In addition, you can and should get help from the beginning of the process when you think your claim may be complex. Workers’ compensation attorneys offer free consultations, so it never hurts to speak with a lawyer. There is no obligation to you, and you can learn more about your claim and the legal process. Then, you can decide whether hiring an attorney for your case is worth it. Reach out to a personal injury lawyer.