Common Reasons Claims Are Denied

The claims process for workers’ compensation can be notoriously complex and difficult to navigate. Each employer should make every available effort to smooth the claims process before it starts by providing adequate training to employees, including managers, and making sure that there are definite procedures in place for the process. Despite best efforts, claims can be denied. Understanding common reasons behind an initial claim denial can assist in smoothing the process.

 

One of the most common reasons for denial of an initial claim is filing a claim after termination .  In California, the statute of limitation on workers’ compensation claim is one year from the date the employee suffered the injury. If the injury was cumulative, meaning it was sustained little by little over time, this could be an exception. If the claim is filed after the statute of limitation has passed, the claim will probably be denied.

 

Another reason could be that the documentation backing the claim is inadequate or inaccurate. An employee needs to provide as much detailed and compelling medical documentation as possible. This includes not only the initial diagnosis, but also how this injury impacts the employee’s ability to work. Just because an employee provides documentation that he or she is injured, even if that injury seems significant, this is not enough. A key component of a workers’ compensation claim is determining an employee’s level of disability. Inadequate documentation supporting a workers’ compensation claim will likely result in the claim being denied.

 

A dispute between the employee and the employer is another common reason for claim denial. An employer may contest a workers’ compensation claim for a number of reasons. For example, an employer may dispute that an injury actually occurred in the scope of employment or that an injury occurred at all. In such a situation, it may be necessary for the employee to gather even additional evidence to resolve the dispute from the employer. Employers should be vigilant for a lack of documentation or other possible signs of fraud, and not be afraid to request additional proof. Workers’ compensation claims may increase an employer’s insurance premiums, so an employer needs to make sure that any potential claims are valid.

 If you have questions about your business and the workers’ compensation claims process, contact me today at (714) 516-8188. The claims process can be complicated, and you need an experienced attorney to walk you through it.

Types of Benefits Awarded

Workers’ compensation provides a safety net that is often essential to the financial stability of employees who have sustained work-related injuries. Workers’ compensation allows an employee to receive benefits from his or her employer or the employer’s insurance carrier in order to cover the medical costs or living expenses. To this end, employers are required to carry workers’ compensation insurance to make sure employees are taken care of. Workers’ compensation in California provides for a variety of different types of benefits, depending on the injury.

Total Temporary Benefits are the type of benefits that are paid when an employee’s work-related injuries are so severe that he or she is completely unable to work, or where the employer is not able to provide accommodations to allow the employee to return to work under necessary temporary restrictions. This type of claim is paid at the rate of two thirds of an employee’s weekly earnings, up to a maximum of $1172.57  in 2017.

Temporary Partial Disability is designed for injured employees who are able to return to work, but not to the extent to which he or she worked before sustaining an injury. For example, if an injured employee is only able to work part-time instead of full-time, he or she may apply for this type of benefit. In such a case, an employee would be entitled to benefits that are proportionate to his or her disability, and he or she would be entitled to two thirds of the difference between what the employee made before the injury and after the injury.

Permanent partial disability is available once an employee has reached the maximum recovery and is able to return to work, but with limitations. The amount of disability paid to the employee is determined according to a statutorily scheduled amount. The length of the disability payments will be determined by the percentage of the disability.

Total permanent disability can also be available, although it is rare. If an employee is completely disabled, such as no longer has the use of arms or legs or has gone blind, then he or she may  receive disability payments for life. Finally, death benefits could potentially be available if an employee dies as the result of a work-related injury.

Workers’ compensation is a vast system, and you need an experienced attorney to walk you through it. I have extensive experience assisting my clients and their business in all stages of workers’ compensation claims. Contact me today at (714) 516-8188 to talk about your options and your business.

Regional Overview of California Workers’ Compensation Claims

Workers’ compensation is a system designed to make sure that employees who sustain work-related injuries are able to get the treatment they require. When handled properly, it can also help protect employers from liability. Different industries have different rates of workers’ compensation claims, as some types of jobs involve an inherently higher level of danger. Just as the frequency of claims varies from profession to profession, it also may vary by region.

A report released by the California Workers’ Compensation Institute determined that employees in California’s Central Valley have a different claims experience that those workers in other areas. The study determined that the time lag between when the employee notifies the employer of the work-related injury to the notification of the administrator to the initial treatment of the employee are significantly shorter than other regions in the state. The study went on to find that after twenty four months have elapsed after the initial injury, Central Coast claims average more medical visits for the purpose of rehabilitation, evaluation, management, or chiropractic care. The biggest difference, though, was in the surgery rate. Central coast workers’ compensation claims after 11.2 percent more medical payments for surgery than the rest of the state. However, the claims in the Central Coast seem to run significantly faster than in the other regions. The average claim lasts 325 days, which is two and a half months shorter than in other parts of the state. This is consistent with the fact that claims are addressed more quickly in this region over all. In 2015, the Central Coast accounted for 7.7 percent of all work-related injury claims in the state. Over the span of the last eleven years, the Central Coast accounted for an average of 6.7 percent of all workers’ compensation claims.

A large proportion of the claims reviewed in the study were agricultural claims. Almost eighteen percent of the claims involved in the study were agricultural claims. Despite this overall percentage, in the Central Coast, only 2 out of 10 job injury claims were related to agriculture.

 If you have questions about your business, workers’ compensation, and whether your business is taking the proper steps, contact me today at (714) 516-8188. I am highly experienced in guiding my clients through this area of law.

How the Employer Can Smooth the Claims Process

As an employer, it is important to understand your responsibilities under the California workers’ compensation system. Unfortunately, the system can be complicated and confusing. No employer wants to hear that his or her employee has suffered a work-related injury. However, if certain steps are taken before the injury has happened, then a business may smooth the claims process. These steps can help take out some of the confusion and stress that typically accompany any involvement with the workers’ compensation system.

The first steps should be taken before an injury actually happens. Reviewing your safety procedures, implementing a safety program, and creating safety committees are all ways that you can make sure that your workers are as safe as possible. A business owner should also make sure that proper training is provided not only to new workers but also existing employees and managers. Create a written guidebook for managers to review and learn so that they all understand the steps that must be taken in the event that an employee does sustain a work-related injury.

If an employee is injured on the job, the employee should be provided immediate and appropriate medical attention. Even if an employee tries to downplay the severity of the injury, he or she should be encouraged to obtain assistance. Ignoring injuries can exacerbate the condition, leading to higher costs for the business because of aggravated injury. This is especially the case where soft-tissue injuries are concerned. Discuss possible accommodations for the worker with him or her, as well as the treating physician, where appropriate.

The claim should be immediately reported to the insurance carrier. If there are witnesses, their statements should be taken promptly, while their memories are fresh. Similarly, all the paperwork required by your insurance carrier needs to be completed promptly. Delaying this essential paperwork will only prolong the process. Business owners should be involved and diligent in this process, and review the details in the paperwork to ensure accuracy. It can also be important to stay engaged and interested with the injured employee. This can help to get a more precise idea of the nature of the injury, different accommodations that should be made, and when he or she would be likely to be able to return to work.

The workers’ compensation process can be confusing, and you need an experienced attorney to help guide you through the claims process. Contact me today at (714) 516-8188. We can review your business and make sure that you are doing all you can to smooth the claims process.

Importance of Clarity in Workers’ Compensation Claims

Workers’ compensation law is a quite complicated and nuanced area of law. Employers should actively seek out clarification on new and existing workers’ compensation regulations and laws, as well as endeavor to have a good understanding on the way the current process works. Failure to have a firm grasp on the workers’ compensation system and the laws associated with it can prove disastrous for both the employer and the injured employee. It is essential that all involved in the workers’ compensation system provide as much clarity as possible in every workers’ compensation claim.

At the beginning of every workers’ compensation case, a worker who has sustained a work related injury must provide a written report. This report details the circumstances surrounding the injury as well as the basic nature of the injury sustained by the worker. It is very important for the worker to be as detailed as possible in this report because the employer and the workers’ compensation insurance provider will both use this report as the “jumping off point” for their respective investigations. The more detailed and accurate this written report, the better starting point the employer and insurance provider will have.

After the initial claim is submitted to the insurance company, the claim will be reviewed and either accepted or denied. If a written claim is not sufficiently detailed or if it is inaccurate, that will greatly increase the chances of it being rejected. Providing the most amount of detail and, more importantly, making sure those details are accurate, will speed up the process. Accuracy will reduce the chance of the insurance company rejecting the claim.

After the claim is eventually accepted and approved by the insurance company, the next issue is the amount and nature of benefits that will be granted to the worker claiming a work-related injury. It is essential that the report to the insurance company is accurate as that will be greatly determinative for the amount and nature of benefits awarded to and received by the injured worker. If the insurance company receives an inaccurate report or case file, it will be impossible for the injured worker to receive the proper amount of benefits.

If you have questions about the contents of a workers’ compensation report, contact us today at (714) 252-7078. We have extensive experience helping clients with this process.

Death Benefits and Workers’ Compensation

Workers’ compensation laws and insurance provide that if a worker is injured on the job, he or she is probably entitled to some form of compensation. If the worst happens and the worker dies in a work-related incident, workers’ compensation benefits do not expire with the worker’s life. California law provides measures for the deceased worker’s family to collect workers’ compensation benefits if the worker is killed in a work-related incident. These are called “death benefits” and are available to certain individuals who may have been dependent on the deceased worker for financial care or support.

Not everyone  is eligible to receive death benefits. A person must demonstrate that he or she was fully or partially dependent on the deceased employee in order to receive death benefits. A person may receive benefits if he or she was fully or even just partially dependent on the deceased worker. Usually a person must have been part of the deceased employee’s household in order to be considered dependent, such as a child or a spouse. The person must also have relied on the deceased employee for financial support.  Some family members are considered under California law to automatically be fully dependent, including children under the age of 18, mentally disabled children of any age (if that child is unable to make their own living), or a spouse that earned less than $30,000 in the twelve months preceding the employee’s death.

A dependent may apply for two different types of workers’ compensation benefits. One of these is burial expenses. The workers’ compensation covers reasonable burial expenses, up to a maximum amount of $10,000. The other type of benefits, as mentioned above, are death benefits. The amounts are $250,000 for one dependent, $290,000 for two dependents, and $320,000 for three or more dependents. If there is more than one full dependent, typically partial dependents will not be eligible for death benefits. If that is the case, the partial dependent may apply to receive four times the annual amount that he or she received from the deceased worker.  Moreover, a child under the age of 18 will continue to receive monetary payments until he or she reaches the age of majority. If there is more than one child, these payments continue until the youngest child turns 18. The calculation of Death Benefits for multiple dependents can be complicated.

If your business is facing a workers’ compensation claim for death benefits, contact me today at (714) 516-8188. We will discuss the elements of the claim with you and your business’s potential obligation to the deceased’s dependents.

Workers’ Compensation and Third-Party Claims

In California, an employer is required to carry workers’ compensation insurance to make sure that injuries suffered by employees in work-related incidents will be covered. However, there are some situations in which an employer may not be completely responsible for an employee’s injuries. For example, if an employee is injured because of a scaffolding collapse, and the scaffolding company negligently produced the product, then there is an additional issue in the case of the scaffolding company’s liability. This is called a third-party claim, and provides options for both the employer as well as the injured employee.

If an employee’s injuries were influenced by the actions or negligence of a third-party, then the employee has a cause of action against that third-party. The employee has the right to bring a case against the third party for their actions at the same time the workers’ compensation claim is pending. The employee would bring a personal injury lawsuit against the third party, which is obviously different than a workers’ compensation claim against an employer. This is called a “cross over case”. In the personal injury case, the employee will need to prove that the third party’s negligence or actions contributed to the injury.

In the event the employee wins the suit against a third party for the personal injury, then the employer has the right to be reimbursed from the money award received by the employee for any workers’ compensation benefits already paid by the employer. The reason for this is to prevent an employee from “double dipping,” i.e. receiving an award from the employer and also an award from the third party for the same injuries.

In order to recover any amounts under this theory, an employer has several options. The first would be to settle with the third party out of court. If this is not an option, the employer can also directly sue the third party. The employer may also join in the action already filed by the employee. Finally, there is also a possibility for the employer to file a lien against an award. If the employer takes the option of filing a lien against the employee’s award, the employer will only get paid after the employee’s attorneys’ fees and litigation expenses have been paid out of the settlement.

If your business has the potential of a third party case, you need an experienced attorney on your side. Call me today at (714) 516-8188 for an appointment to discuss your business’s third party claim.

Secondary Injuries – Kesner v. Superior Court

An employer is typically liable for work-related injuries sustained by employees. For this reason, the state of California requires all employers to carry workers’ compensation insurance to cover their employees’ possible work-related injuries. In some cases, though, a third person may sustain injury indirectly from the employee’s job. This third party could be a family member or other person the employee comes into contact with regularly. Where does a employer’s liability end?  This issue was explored in a case called Kesner v. Superior Court.

In Kesner, the plaintiff was the nephew of the employee of the defendant, Abex. The plaintiff was diagnosed in February 2011 with perotineal mesothelioma. His claims against Abex were based on the fact that his uncle worked at the Abex company for many years. During those years, the plaintiff was a frequent visitor at his uncle’s home. His uncle would come home from his job at Abex covered in asbestos dust. The uncle would then play with the defendant, and sometimes sleep near him. The plaintiff alleged that the exposure to the asbestos dust lead to him eventually contracting mesothelioma.

Abex successfully moved to have the case against it dismissed, based on the fact that the plaintiff was not an employee, and Abex owed him no duty of care, which is an essential element of a negligence claim. However, the plaintiff appealed that dismissal and was successful. The court concluded that Abex’s duty of care did, indeed, extend to the plaintiff. The court ruled that Abex could have foreseen that the harm of the asbestos dust could have extended to the third-parties residing in an employee’s home. The court was careful to delineate the harm from a tangible injury such as mesothelioma from intangible harm such as mental anguish, which the court had previously ruled was not covered by third-party liability theories. The court also emphasized that the plaintiff in this case had extensive contact with his uncle. If the contact with the third-person was incidental or occasional, an employer would not be expected to foresee such an injury.

From this case, it is clear that an employer’s liability for work-related injury does not always end when an employee physically walks out of the work-place. Employers need to be cautious about foreseeable injuries to third-parties, such as family members, as they could ultimately be held responsible for such injuries.

If you have a question about secondary injuries, contact me today at (714) 516-8188. We can discuss your business, and review its responsibilities and possible foreseeable injuries.

What is the UEBTF

Under California law, all employers (with very few exceptions) are required to carry workers’ compensation insurance. This law is meant to ensure that all employees injured on the job will receive fair compensation. Even if an employer does not carry the mandatory insurance, an employee with a work-related injury is still entitled to compensation for medical treatment and other related benefits. In the case where an employee is injured while working for an uninsured employer, the employee may apply for benefits from the Uninsured Employers Benefits Trust Fund (UEBTF), which is funded through a tax that is placed on every workers’ compensation policy premium in the state of California, as well as fines and penalties collected from any illegally uninsured employers.

The UEBTF is a fund held by the State of California to make sure that employees with work-related injuries can still obtain the monetary benefits they would receive if they had been working for an employer who held the required workers’ compensation insurance. The UEBTF was established in 1971 in an effort to make sure that employees with work-related injuries receive compensation even if their employer was illegally uninsured. An employee who receives a work-related injury may seek a judgment from the Workers’ Compensation Appeals Board (WCAB) for the amount of their medical costs and other injuries as allowed by California workers’ compensation law. After an employee receives an award from the WCAB, then he or she may apply to the UEBTF for compensation if the employer was not insured at the time of the injury, and the employer fails to pay the award within 10 days.

If an employee successfully receives compensation from the UEBTF, that does not mean that the uninsured employer is off the hook for the costs of the employee’s medical care or other expenses. After the UEBTF expends funds to compensate the employee, the UEBTF will then seek to be reimbursed for those expenses paid by the UEBTF from the uninsured employer. It does this by seeking to place a lien on the assets owned by the uninsured business. The business will receive a Special Notice of Lawsuit before the UEBTF becomes a party.  After the UEBTF becomes a party,  a lien can be placed by the UEBTF on all assets of the business and any substantial shareholders. Recoveries from illegally uninsured employers are another source of funding for the UEBTF.

If you are facing a lien or action from the UEBTF call me today at (714) 516-8188. I look forward to discussing this process with you and helping your business with the complicated issues associated with it

What Violates 132(a)?

California Labor Code 132(a) clearly states that the policy behind this section is that there should not be discrimination against employees who are injured at work. The code goes on to outline that any employer who takes adverse action against an employee due to the employee making a workers’ compensation claim is subject to both civil and criminal penalties. These penalties can be severe, and it is important to have a firm grasp of what does and does not violate the terms of section 132(a).

The most obvious type of violation is where an employer takes direct adverse action that is discriminatory. An employer will expressly violate the statute if the employer terminates or threatens to terminate the employment of an employee because the employee has filed or expressed the intention to file a workers’ compensation claim, the employee receives an award for a workers’ compensation claim, or testified before the Workers’ Compensation Appeals Board for another employee’s claim. The employer will also have expressly violated this section for discriminating against the employee in any way for these same reasons. Discriminatory action can include such actions are not limited to termination; they can also include other adverse actions, such as changing a shift to hours the employer knows the employee cannot work. The law also covers other discriminatory acts by the employer, such as when an employee is penalized for being injured on the job or from missing time from their job due to an injury sustained in the workplace.

Insurers are also included in prohibitions under 132(a). An insurer may not tell an employer to terminate the employee because an employee has filed for workers’ compensation benefits, received an award of workers’ compensation benefits, or testified before the WCAB for another employee’s workers’ compensation claim. Under this section, an insurer is prohibited from telling an employer to fire an employee when that is coupled with a threat to cancel a workers’ compensation insurance police, to raise the insurance premium, or other adverse action against the employer.

These cases are typically filed in conjunction with an underlying workers’ compensation claim. The employee must do more than simply allege that they suffered adverse consequences from the employer. The employee must also prove that they suffered these adverse actions because of their workers’ compensation claim.

It is very important to protect your company from potential claims under 132(a), as a successful suit can be very financially damaging or even fatal to your business. If your business is facing a suit under 132(a), contact me today at (714) 516-8188 to discuss it.

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