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Worker’s compensation insurance carriers often hire “Independent Medical Examiners” or “IME” doctors to review your claim. There is nothing “independent” about those doctors. They are hired guns. When your doctors support the work injury, ongoing treatment, and disability from the work injury, the insurance carrier is obligated by law to provide you with benefits unless they have a contrary opinion from an IME, or another defense. Sometimes the IME doctor will agree with you and your doctors but most of the time they do not.
Many doctors who provide these “independent” medical examinations make a lot of money examining dozens of worker’s compensation claims every month and they want to continue to be hired in this capacity.
If you see an IME doctor, the exam often lasts somewhere between 5 and 15 minutes. Then, later, you get a report about 10-20 pages long talking about how you had a strain or minor injury that resolved within a few weeks, or that you don’t need any more treatment. The IME doctor can also say that your current problems are due to a pre-existing condition that was not aggravated by the work injury, or say that you are no longer disabled due to the work injury.
You may not even see this doctor Instead the doctor may review your records and provide a written opinion on your condition without ever examining you, called an “Independent Record Review” or “Medical Record Review.” The worker’s compensation insurance company can obtain your medical records without an authorization once you claim a work injury (HIPAA privacy laws for medical records don’t apply once you make a claim for worker's compensation).
If your claim has been denied by an IME doctor or a medical record review, contact us right away. The good news is that most worker’s compensation judges know the score on these doctors, although that doesn’t mean you will win. Worker’s compensation judges are administrative judges who cannot take sides - they must preside over hearings for benefits in a fair and impartial manner. To be successful in winning your claim, you will need to present the best possible case against the insurance company - Luke Kingree, with his knowledge of the law and the system, will challenge the results of the IME or medical record review and work with your doctors to ensure that the judge knows the real cause of your injuries.
When your claim is denied, worker’s compensation insurance carriers often send you a letter stating that if you disagree with their decision you can contact the Department of Workforce Development – Worker’s Compensation Division for information on how to appeal. The letter also says you have the right to apply for a hearing and can contact the Division for a hearing application. Like most legal processes, there are rules and practices that are not apparent in the law or the materials provided to explain the law. To file an effective appeal, you need someone with experience working within the system and knows how the process works.
Filing an appeal on your own is always challenging. You’ll be sent forms and basic information on how to appeal. You will not be given information on how to win your case. You won’t be given answers to questions on your medical treatment, what to do to make ends meet, how to navigate issues with your employer, or what happens after the process is over. Most importantly, you won’t be told how to maximize your benefits or all the benefits that you may be entitled to. You will need an experienced and dedicated Wisconsin worker’s compensation attorney. Contact us to ensure that you receive all the benefits to which you are entitled.
Your employer must accommodate your temporary or permanent restrictions if they can reasonably do so. Your employer is not required to “make work” for you if none is available. If they do not bring you back to work and you are in the healing period before all your treatment has ended, you are entitled to temporary wage loss benefits. If they do not bring you back to work after you have reached the end of healing and you have permanent restrictions, you may be entitled to more than just the permanent partial disability (PPD) benefits your doctor assigns. You may be entitled to retraining (education) or loss of earning capacity benefits.
If your permanent restrictions cause a wage loss, even if you have returned to work at your employer where you were injured, you may be entitled to retraining (education) or loss of earning capacity benefits. Your employer cannot retaliate against you for claiming these worker’s compensation benefits. Contact us for a better understanding of the benefits that are available to you to minimize the impact of a job-related injury.
If your employer refuses to bring you back to work unless you are “100%” or you have no restrictions, what happens next depends on your situation. If your claim has not yet been denied by the worker’s comp insurance carrier, and you are in the healing period still receiving medical treatment for your injury, you should receive a wage loss benefit from the carrier. There is often nothing that a worker’s compensation attorney can do to force the employer to bring you back to work, even if work is available within your restrictions. Your only remedy is the wage loss benefit from the worker’s comp carrier while in the healing period. An employer cannot terminate you for filing for worker’s compensation benefits and if your employment has been terminated contact us right away.
If your worker’s comp claim has been denied, but you are still in the healing period, you won’t receive any wage loss benefit and you will be in a difficult financial position. See the answers to other FAQs here and here. Contact us right away if this occurs. Your claim has been denied and you will need an attorney to fight for your rights and maximize the benefits that you can recover in an appeal.
See previous FAQ on employers not bringing you back to work. Contact us right away, and see below.
If you are injured and still in the healing period getting medical treatment, you can’t work because you are injured, and you don’t have any money coming in because you are not working and your worker’s comp claim has been denied. It is a Catch 22 and a vicious circle. The only way out of that circle is to get medical treatment, use your health insurance to obtain medical treatment, and get as better as possible as quickly as possible. Once you are finished with treatment and your doctors release you from their care, your appeal of the denial can be settled or set for a hearing in front of a worker’s compensation judge. You should contact us during this time, as you will need our representation in filing the appeal and maximizing the benefits available to you. We can also provide you with advice on what to do in the meantime and what your options are after the appeal.
Most of the time, no. The unfortunate reality is that once a worker’s compensation claim has been denied – usually from an IME – there is often nothing that any person can do to get the worker’s comp insurance company to pay anything again anytime soon. An appeal must be filed, a hearing will be held, and the insurance company’s defense will need to be defeated. You should contact us right away to begin this process.
Unfortunately, there are few other sources of income available to injured workers whose claims have been denied. You can attempt to obtain another job within your temporary restrictions if your employer does not bring you back to work, but doing so would reduce the worker’s comp benefits that can be claimed. Otherwise, you may have to make do with support from friends and family. You should contact us right away for representation in your case and further advice.
In some situations, people ask about getting on disability, SSDI, or early retirement due to the work injury. You can claim SSDI and still get worker’s comp benefits at the same time, but receipt of SSDI may reduce some of the benefits in the worker’s comp case. You can claim Social Security retirement benefits and still claim worker’s comp benefits without any offset. If you have long term disability insurance, disability pension through the State, or other disability benefits available to you, those can also be claimed at the same time as worker’s comp benefits, but again there can be reductions in the value of the worker’s comp benefits and also repayment clauses in contracts to consider. Contact us for advice on how all of these disability and retirement benefits interact with worker’s comp benefits.
Many injured workers receive medical bills for treatment from a work injury. You should provide your medical clinics with the worker’s compensation claims adjuster’s contact information and ask the clinics to bill the worker’s comp carrier directly. The carrier must pay those medical bills within a reasonable period of time unless they have a defense. It is common for it to take 90 days or a bit more. If you are still receiving medical bills from your clinics more than 6 months after the bills were incurred, and your clinics have been billing the worker’s comp carrier, contact us right away.
There are no copays or deductibles for medical treatment under Wisconsin worker’s compensation law. The carrier must pay everything unless they have a valid defense to the claim. If you have out-of-pocket expenses for treatment, or the worker’s comp insurance company won’t pay for your medications and prescriptions, contact the Worker’s Compensation Division. Dispute resolution specialists there may be able to assist you with minor disputes.
If your claim has been denied and you have significant unpaid medical bills, contact us right away.
This is called a “Nurse Case Manager.” You do not have to allow this person to be in the room at medical appointments, and you can instruct the nurse case manager to only communicate with your doctors in writing. You also do not have to tell the nurse case manager any of the details of your visit with the doctor. Taking this step may anger the claims adjuster, however, and result in a denial of benefits.
The Nurse Case Manager is basically a paid spy for the claims adjuster. Their job is to report back to the claims adjuster regarding your treatment and try to influence you and your doctors. Some are helpful to you and your treatment, while others are definitely not. If the nurse case manager tells you that you must seek a certain type of medical care or see a certain doctor, you have the right to say “no,” unless the doctor they want you to see is an “Independent Medical Examiner.” Remember, however, that an Independent Medical Examiner only evaluates your condition, he or she does not provide you with any medical treatment. Contact us if you are sent for an independent medical examination and the doctor performing the examination recommends treatment, tries to treat you, or otherwise makes you feel uncomfortable or unsettled.
This is a very common issue. The worker’s compensation insurance company is not your insurance company; they are your employer’s insurance company and acts in the interests of your employer. You are not the premium payer or the policy holder. You are the “problem” or the “loss.” The insurance company has no incentive to give you a pleasant or easy experience. They want to save money. They do not care about you, and they are not required to provide you with full information.
Unfortunately, there is little that can be done about this dynamic. The best option is to communicate clearly and respectfully, with the understanding that the claims adjuster does not care about your experience or how this process impacts you. There is no pain and suffering in Wisconsin worker’s compensation claims. All the adjuster often cares about is whether you have restrictions, whether you have shared those restrictions with your employer, whether the employer has offered you work, whether you are sustaining a wage loss, whether you are receiving medical bills, and when your next medical appointments are.
However, if the adjuster does not pay the benefits you are entitled to without a valid defense, contact us right away. Also contact us right away if your claim has been denied.
If you have temporary medical restrictions and your employer has not brought you back to work, the worker’s compensation insurance carrier must pay you 2/3 of your gross weekly wages as of the time of the work injury. This is called temporary total disability (TTD). You should be paid every week or every two weeks at the most. If the carrier is constantly late with payments, or if the payments are inconsistent, the best bet is to contact the Worker’s Compensation Division. Dispute resolution specialists there may be able to assist you with minor disputes.
However, if your checks are more than 2 weeks overdue, contact us today. Also contact us if the carrier has never paid TTD despite the fact that you are off work entirely with medical restrictions.
If you are back to work on light duty and making less than you were before the injury, and you are still in the healing period and have temporary medical restrictions, you are entitled to temporary partial disability (TPD). Your employer is required to provide your wage records to the worker’s compensation insurance carrier and they must calculate your TPD and send it to you. It is 2/3 of the difference between your light duty earnings and the gross weekly wages you were making before the injury.
It often takes more than 2 weeks for the claims adjuster to calculate and send your TPD checks after receiving your wage records from your employer. However, if you have not received TPD checks more than 4 weeks after you sustained the wage loss, if the carrier has never paid TPD despite being provided the wages by your employer, or if your employer has never provided wage records to the carrier, contact the Worker’s Compensation Division. Dispute resolution specialists there may be able to assist you with minor disputes.
Contact us today if your claim is denied and you have ongoing partial wage loss, or if your partial wage loss is permanent.
There is no pre-approval of medical treatment in Wisconsin worker’s comp claims. This is different from many other states’ worker’s compensation systems, and it is unlike your traditional health insurance. A worker’s comp carrier is not required to pre-approve any treatment, but they may do so as a courtesy.
Instead of pre-approval, Wisconsin’s system requires something of a “leap of faith.” You have the procedure and your medical clinic then sends the bill to the worker’s comp carrier. The carrier must pay unless they have a defense. You should always have health insurance as a backup in the event the carrier asserts a defense to your claim and refuses to pay the bill.
If your clinic refuses to schedule a medical procedure without pre-approval from the worker’s comp claims adjuster, you can attempt to obtain a courtesy pre-approval from the claims adjuster, but again they are not required to pre-approve any medical treatment. The clinic needs to simply schedule the procedure and bill the worker’s comp carrier if the claim is still being paid.
See the medical treatment section for further information on denial of medical expenses. Your clinics can also see our For Referring Professionals tab for further information. Contact us if you are having difficulty receiving treatment for a workplace injury, either from the Worker’s Compensation carrier or your health insurance carrier.
Worker’s compensation insurance carriers can deny a claim at any time. A denial can be asserted immediately after the claim is filed or it can be months or even years after the work injury. Even after paying benefits for a long time, nothing in the law prevents the insurance company from asserting a defense or denying the claim later. It is actually quite common for a carrier to get a report from their IME doctor saying that no injury occurred, or it was a minor injury that healed a long time ago, and the carrier never should have paid benefits to begin with.
If your claim has been denied, no matter what stage, contact us today. There are often benefits we can claim in addition to what has already been paid. We can also help if the worker’s comp insurance company says it may try to get money back from you after a denial.
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