Frequently Asked Questions
Unless your case is denied, the workers' compensation claims adjuster must authorize immediate medical care with an appropriate treating physician. If your case is denied, the claims adjuster is not obligated to provide you with any medical care. You will need to challenge the denial of your case by taking your case to a workers' compensation judge. For this reason, if your case is denied, you should seriously consider retaining a competent workers' compensation attorney.
The claims adjuster should make arrangements for your medical care with an appropriate treating physician. That physician should examine you and prepare medical reports about your care. Those reports will be used to determine the nature and extent of your benefits in your case.
You may disagree with the kind of medical care your physician is providing. If so, you have the right to change your care over to a different physician. If you do not receive information on how to change the physician, or you do not understand how to change the physician, you should seriously consider consulting with a competent workers' compensation attorney.
The treating physician will report if you can return to work, or if you can return to work with restrictions. The physician can report that you are temporarily unable to return to work because of your injury. At the conclusion of each of your appointments, the physician should hand you a Work Status Report. You need to provide a copy of that report to your employer. If the report states that you cannot return to work, or if your employer will not accept you with the work restrictions described in the report, the claims adjuster should pay you temporary disability benefits.
When the claims adjuster receives a physician's report recommending medical care, the adjuster can either authorize the recommendation, or the claims adjuster can send the report to Utilization Review (UR). UR will have another physician review the recommended medical care. UR will inform the claims adjuster if the recommendation should be authorized, if the recommendation should be authorized in part, or if authorization should be denied in its entirety.
If the recommended medical care is only authorized in part, or it is denied completely, you have the right to challenge that decision. The claims adjuster MUST provide you with specific documents: a copy of the UR decision; the physician's report that made the recommendation; AND an Independent Medical Review Application form. That form should be fully completed by the claims adjuster with all of the necessary information. Use that form immediately to challenge the UR decision. You only have 30 days to submit your challenge. You will have to sign the Independent Medical Review Application form. You can either fax or mail your challenge. Be sure to include the signed Independent Medical Review Application form; the UR decision itself; and the physician's report. If the physician tells you the claims adjuster has denied authorization of his or her medical care recommendation, and the claims adjuster did not provide you with the above specific documents, you should seriously to consider retaining a competent workers' compensation attorney AS SOON AS POSSIBLE.
The claims adjuster has strict deadlines to legally partially authorize or completely deny authorization of medical care recommendations from the treating physician. If the claims adjuster's decision is LATE, a workers’ compensation judge can order the recommended medical care without further delay. However, there are many technicalities involved in successfully taking the challenge to a judge. You should seriously consider retaining a competent workers' compensation attorney to challenge the LATE decision.
The claims adjuster can decide to "deny" certain injured body parts or medical conditions claiming they are not related to your work injury. This is different than denying authorization of recommended medical care to body parts or medical conditions that have been accepted. Specific body parts or medical conditions can be denied even though the case is admitted. The claims adjuster will not pay the treating physician for care to any of the denied body parts or medical conditions. For this reason, you will need to challenge any denial of body parts or medical conditions as soon as possible. To that end, you should seriously consider retaining a competent workers' compensation attorney.
There are two types of settlements in workers' compensation cases:
1. Stipulations with Request for Award; and
2. Compromise and Release.
Hay dos tipos de resoluciones de casos de Compensación a Trabajadores: