thursday asked me to repost this response to her "Sweating over claim closure," so bear with me, some of it might be repetitious:



I was a Senior Claims Examiner with over 13 years of experience in worker's compensation in several states before my last employer put me on disability. Let me preface by saying every sate is different. I urge anyone on W/C to read the basic on how your state's w/c works.


A claim will stay open as long as your doctor can document that further treatment will improve your condition. Once he can no longer justify your being in treatment (even if the physical therapy, etc. keeps you from sliding backwards), you will likely be declared fixed and stable. At that point your claims examiner with do one of several options: a) prepare the claim to be closed, b) request a permanent disability evaluation from your doctor, or c) set up an independent medical evaluation for determination of permanent disability and/or restrictions.

I advise anyone nearing claim closure, that unless you feel just as healthy and fit as you did before your injury, and sometimes even if you do, request a permanent disability rating from your doctor. If he can not do one (not all doctors have the certification to do this) ask him to refer you to a doctor for a consultation for closure and determination of permanent impairment.

A permanent disability or permanent impairment rating should take into account all factors such as loss of strength, loss of range of motions, loss of sensation, residual pain, your age, and perhaps even your physical condition, and your education level. If your hand is injured, ask that your rating be to the arm, if your thumb, to the hand, etc. If you have a back, shoulder or hip injury it should automatically be rated as loss to the body as a whole. However, remember, your state may vary somewhat . . . but you can ask for a copy of the statute on disability/impairment (they are the same thing) ratings.

I urge you to not let your claim be closed without addressing permanency unless you truly feel so fully healed that you can not imagine ever having the injury site give you any grief as far as being able to work. Disability is rated with regard to ability to work, not with regard to bowling, playing golf, or climbing mountains or skiiing! (I have had every question in the book asked of me regarding sports and activities that a claimant could no longer do.. . . but unless it is a work activity, your industrial injury is most likely not going to be responsible.)

You will not get rich from your permanent impairment rating and award. It likely will seem like a mere pittance for what you have been through, unless you have suffered a severe injury like amputation or a severe head or back injury, requiring major surgery or extensive rehabilitation. if your rating seems too low, ask the doctor to explain how the figure was determined. If the state arranged your independent/rating exam and it seems unfairly low, ask for a second opinion, with your own choice of doctor.

Carpal tunnel surgery never used to carry an impairment, as it was believed surgery restored 100% function, but that was changing when last I worked. Fractures of the arms, hands, legs and feet should be rated for impairment, as should back injuries with residual pain and/or loss of flexibility, even if you did not have surgery. Hearing loss always has impairment, as does loss of sight, taste, or any of your senses. I once paid impairment for a claim for loss of the sense of taste when the treatment for the injury caused the loss, even though the injury itself did not. I also paid out a huge claim on top of the work injury when a therapist treating the work injury dropped a patient and cause paralysis! (The additional costs for the second injury went to subrogation, meaning the therapist was responsible for everything over and above the initial injury . . . but it was messy, as the patient was not nearly to the end of her treatment when the therapist dropped her!)

(Speaking of subrogation, if a third party is responsible for your injury, they will have an interest in what is paid out on your claim. However, do not let them have undue influence over the claim, or push for closure, early end of treatment, or less treatment than necessary. And do not deal with them directly . . . your employer or the claims person is responsible for dealing with this.)

The best way to deal with your claims person is to be calm, reasonable, not angry or upset, and to educate yourself as best you can, as this will get their attention. The worst thing you can do is threaten, act like you are or have an attorney (your ability to talk directly with a claims person, and sometimes even your employer, about your claim, ends when you get an attorney), or indicate that you expect to "own the company" once your claim is settled. Believe me, I have heard it all where closure, money and punishing "bad" employers and their representatives are concerned.

I used to tell my claimants who asked up front if they would need an attorney on their case: "not if I do my job correctly." And then I would tell them if at any time they feel they can no longer get what they think they need from me or the system, then that is when they might want to speak to an attorney. Fees can range from flat-rate hourly with the clock ticking on every phone call, even the ones that are not returned (number one complaint about attorneys is that they do not return client calls on w/c claims) to anywhere from 20% to 30% and more, plus expenses/costs. Some of the best reasons to get an attorney are:
1. Your claim is denied and you truly had an on the job injury. Not an accident, but an bona fide injury. An attorney will know how to best present your case before whatever review board your state provides.
2. Your claim is only allowed for part of the injury and you or your doctor feel that your injury is greater than what was allowed.
3. You are refused benefits and you have been unable to protest them out of your claims person. Remember, every order issued to you is likely able to be protested in writing. Learn to write a decent and neat (with spell check) business letter. It is beeter then righting one that culd make them laff and not take yu seeriusly.
4. Your claim is closed before you have finished treatment. Your doctor should protest this, but if he doesn't convince them, you might need an attorney.
5. If, in your state, your employer/claims person has the right to dictate which doctor treats you, and this doctor is seriously downplaying your injury, an attorney might be needed.
6. If your claim is closed without a disability rating and your claims person disregards your second opinion doctor's rating. Attorneys love ratings cases because they know approximately how much money they will make and have to spend to get it.
7. You have not received all of your time loss/loss of earning power benefits and your examiner closes your claim. After you have submitted a protest with your calculations, if you still feel they owe you for lost time or lost income benefits, you may need to get an attorney. Included here would be if your time loss rate was not calculated accurately, or does not include shift premiums, overtime or bonuses in the calculation. However, these usually must be protested within a specified period after you have received an order for payment and calculation of benefits. Do not miss this deadline . . or any deadlines, for that matter. You will be left out in the cold!
8. Your employer does something that appears to be retaliatory for your filing a claim. e.g. Your employer fires you for filing a claim and ruining their perfect no-injury record, or they treat you differently when you return to work, like forcing you to take a job that pays less even if your job position is available, or move you to another shift when there is an opening on your regular shift. This is a fuzzy area in the law, which is why you should at least ask an attorney if you feel any kind of discrimination or retaliation, and especially if it is for filing an injury claim.

This list is incomplete and may not apply to all cases in all states. I have tried to provide a summary of ideas to help you educate and protect your rights when it comes to on-the-job injuries. Learn if and how to protest any actions you feel are not timely or done improperly. Learn to speak up and stand up for yourself. It will feel like work. . . but hey, you are getting paid something in the neighborhood of 2/3 of what you had been earning before you were injured. Get to work protecting yourself!!!
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