Behind the Scenes:
We hear every day from injured workers how frustrated they are with the Workers’ Compensation system. Often workers have been led to believe that if they get hurt at work then they will get work comp. Unfortunately, it’s rarely that simple. The laws and regulations governing workers’ compensation claims are complex, varied, and often counterintuitive.
One of the major issues impacting injured workers is the fact that the work comp insurance company is the initial gatekeeper to benefits. Before any benefit may be paid to you such as wage loss or payment of medical bills, the insurance company must say it agrees to pay.
Insurers are shrewd businesses that realize they do not make money for their shareholders by paying you your benefits. The work comp insurance companies have built up huge teams of doctors, nurses, vocational reviewers, claims adjusters, and lawyers all on their payroll and all aimed at trying to deny or limit your work comp benefits.
These businesses often set up policies and procedures aimed at:
1) denying benefits as soon as possible, requiring you to fight for every inch of ground
2) delaying and fighting each benefit request.
For example, if your doctor recommends a specific procedure that she thinks will improve your pain and symptoms, insurers often say they will not pay for the procedure until a doctor on their payroll agrees with the treatment. They call these “Independent Medical Examinations” (IME’s), but they are never independent and rarely count as medical exams. Moreover, even if the insurance company’s doctor agrees you need some form of treatment, if their doctor does not exactly agree with your treating physician, the insurer will often deny your doctor’s request and force you to litigate the issue. This opens a whole can of worms. For example, the insurer may now try to refuse payment of wage loss benefits if you decide to proceed with your doctor’s recommendation.
The insurer may use their examination as an attempt to deny your claim outright, even after years of agreeing to pay for benefits. A common example of this is an assertion that you did previously have a work injury, but that this injury was temporary in nature and has now resolved. The fact that you still have significant pain, and require work restrictions, the insurer will argue, is instead due to some other cause like age related degeneration or some pre-existing issue to a body part.
Sometimes an insurance claims adjuster will simply say your injury was not witnessed or that you did not report it right away to your employer (even if you didn’t know you were supposed to) so they are going to deny your claim.
If you have been injured at work, despite what your employer or insurer may tell you, you need to have someone on your side. Attorneys Mike Kemmitt, Evan Sanford and Patrick Kramer have represented hundreds of injured workers in fighting for wrongfully denied benefits or guiding injured workers through the complex web of work comp benefits. Often there are many benefits available to you about which the insurer will simply never tell you. Alternatively, the employer or insurer may tell you something is required under the law when it simply is not required. For most injured workers this is the first and only time they will go through the work comp system and it is absolutely vital you contact Kemmitt, Sanford & Kramer to make sure you are receiving your proper benefits.