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Filing a Claim
A claim should be filed as soon as possible after your injury or occupational disease. When injured, you must give notice to your employer of the claim within 90 days. If you have an occupational disease or repetitive use condition, you may have a more time.
It is best to file a claim using one of these forms:
An 801 form is the form that begins most workers' compensation claims. It is filled out by you and your employer to begin a claim. 801 Form
An 827 form is a form completed by you and your doctor. An 827 form can begin a claim. It can also be used to designate your attending physician and to file an aggravation claim or palliative care request, if your claim is closed. 827 Form
If you are have questions about filing a claim, or need help to do so, please call us.
Injury and Occupational Disease
Workers' compensation covers both work injuries and occupational diseases. Injuries are those events that happen suddenly to cause you harm, such as falling at work. If there are no preexisting conditions, all injuries are covered where there is enough of a connection to work. Sometimes, this connection may not be very obvious. If the worker has a preexisting condition, the work injury should be covered if the work injury is the major contributing cause of your disability or need for medical treatment.
Occupational diseases are those conditions that come about slowly overtime. Some common occupational diseases are hearing loss, wear and tear arthritis, carpal tunnel syndrome and toxic exposure. You may file an occupational disease claim at any time, even after you have stopped working. All occupational diseases should be covered if the overall work exposure is the major cause of the disease.
Claim Denial
After filing a claim, the employer or insurer has 60 days to accept the claim or deny your claim. Your claim denial may be wrong. In fact, almost half of the denials that are contested are proven wrong. If the denial is not challenged within 60 days, all rights will likely be lost.
If you have received a claim denial, or if 60 days has passed and you have yet to receive a notice of acceptance, please call us.
Notice of Acceptance
A Notice of Acceptance means that you will be able to receive workers' compensation benefits for your accepted condition(s). There are two things you should check on this notice. First, does the notice list all of the medical conditions that should be accepted? For example, often the only condition accepted is a "strain", even though a worker has a much more serious condition. Second, does the notice accept your claim as disabling or non-disabling? Only on claims accepted as disabling can a worker be paid for time lost from work, or be compensated for permanent disability or get vocational retraining.
If your Notice of Acceptance does not list all the medical conditions caused by your injury, or if it wrongly lists your condition as non-disabling, we can help.
Time Loss Pay
Time loss pay (temporary disability benefits) should be paid to you when you are missing your regular work due to you work injury. These benefits are not taxed and should be equal to 66% of your average weekly pay. To receive time loss you should always get a doctor note in writing that says you can not do your regular work due to your work injury. Each time you leave the doctor's office, you should take with you a copy of your work restrictions and give these to your employer or worker's compensation insurer.
Your temporary disability may be partial. If your attending physician has returned you to light duty and you are not earning the same pay, you should still receive some time loss pay. You need not report to light duty until you have been offered a job, in writing, that your attending physician has approved.
If you are not getting time loss pay, or if you are not getting paid the right amount, please call us.
Medical Treatment
You have the right to all reasonable and necessary medical treatment for your work injury prescribed by your attending physician. This right to medical treatment continues even after your claim is closed. Sometimes, workers' compensation insurers refuse to pay for your treatment, if this has happened to you we may be able to help.
Your attending physician is the doctor primarily responsible for your medical care in your claim. Your attending physician also authorizes time loss pay, determines when and if you should return to work, and if you need permanent disability benefits. Normally, you can choose your own attending physician and switch doctors at least 2 times. If you are enrolled in an MCO, you must choose a doctor from the MCO provider list.
Notice of Closure
You may receive a Notice of Closure. This is an important document. A Notice of Closure means that the insurer or employer thinks you have finished recovering from your work injury. In this notice, you will be said to have permanent disability, or not. For those who are permanently disabled, there will be an amount of disability. Frequently, there are errors in the Notice of Closure; claims are closed too soon, and some workers are underpaid. An appeal of a Notice of Closure must be filed within 60 days. This is done by filing a request for reconsideration. We can do this for you.
Vocational Retraining
If you receive a permanently disability award, and are not able to return to your regular work, you may be entitled to vocational retraining. You may request a vocational eligibility evaluation, or a vocational counselor may contact you. This counselor is not working for the insurance company or your employer. They are there to help you. If, however, you are not happy with the counselor, or have been denied vocational retraining, you can call us with you questions.
Opening a Closed Claim/Aggravation Claims
Your closed claim can be reopened. There are two ways to do this. First, if your accepted condition has worsened, an attending physician may file an aggravation claim using an 827 form. With this form, it is critical that your attending physician send along a written report, or chart note, explaining exactly how the condition has worsened. Once the aggravation claim is filed, if your attending physician has approved time loss you should be paid for missing work within 17 days. The aggravation claim must be denied or accepted with a Notice of Acceptance within 60 days.
A second way to reopen a closed claim is to file a new or omitted medical condition claim. Sometimes, workers develop new medical conditions caused by their injuries after their claims are closed. For example, a worker who injured their knee years ago at work may now have developed arthritis caused by that injury. In such cases, a new or omitted medical condition claim should be filed.
We can help you reopen your claim.
Third Party Lawsuits
If your work injury was caused by the negligence of a person other than your employer or coworkers, you may be able to file a lawsuit against that third party. This lawsuit is separate and in addition to your workers' compensation claim. Such a lawsuit is filed in state court where you can recover compensation for all your loses, beyond those already paid by worker's compensation, including for pain and suffering.
Therefore, be sure to tell us if someone else caused your work injury.
Social Security Disability Benefit Programs
There are two main types of federal disability benefits: Social Security Disability Insurance (SSDI), which is based on your prior work. To be eligible for SSDI you must have earned sufficient work credits. The other disability benefit program is Supplemental Security Income (SSI), which is based on financial need.
Eligibility for SSDI and SSI
The following criteria apply to both SSDI and SSI:
1. If you are working and your earnings average more than $940 a month, you generally will not be considered disabled.
2. If you are not working you must have a disabling condition. Your condition must interfere with basic work related activities.
3. Some medical conditions are specifically listed in the law as disabling. If you have one of those conditions, you automatically have a disabling condition, and you should be eligible for benefits.
4. Even when your condition is not specifically listed as disabling, you may still have a disabling condition and be eligible for benefits. In such cases, your condition must prevent you from doing your previous work, and it must prevent you from adjusting to other work. When determining if you are able to adjust to other work, your medical condition, age, education, and past work experience are considered.
Filing a Claim
A federal disability claim is filed and processed through a local Social Security Administration field office. Typically within about 120 days, the agency makes the disability determination with a two-person adjudicative team consisting of a medical or psychological consultant and a disability examiner.
If you are denied benefits, you can appeal the initial determination by requesting reconsideration of the initial decision. This initial appeal is usually handled much the same as the initial claim.
Requesting a Hearing
If you have been denied benefits again after the first appeal, you will be sent a notice advising you of the right to request a hearing. An administrative law judge will conduct the hearing, receive additional evidence and rule on your disability for benefits.
You should obtain legal representation at this time to help develop and present your case at hearing.
Filing a Lawsuit
If the administrative law judge denies your benefits, you can make a further appeal by filing a lawsuit against the Social Security Administration in federal court. We have won such cases in the past, and would be happy to consider representing you on such an appeal.
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