Filing a claim

Filing a workers compensation claim can be a confusing process. The following is a detailed list of everything that is involved in filing a workers comp claim correctly.

Oregon Workers Compensation Attorney Portland, OR

A worker compensation claim begins when a worker reports an injury to his employer or doctor. Workers are required by law to report a work injury to their employer IN WRITING. The employer or doctor is then required to notify the insurance company if there is a claim. If you believe you have been injured at work, and you are not sure if your employer has processed your claim, you must report your injury in writing as soon as possible. You should always keep a copy of the report of injury in case it gets lost or there is any question later of whether you reported the injury. The written report can be in any form. Once you have made your written report to your employer, you should be given a Form 801 injury report to fill out and sign. This form can also serve as the written report of injury. The Form 801 is the official “claim” for workers’ compensation benefits.

Hopefully, the insurer will promptly accept your claim. If your claim is accepted, a Notice of Acceptance will be mailed to you at your address. Unfortunately, insurers and claims adjusters will often tell workers their claims are “taken care of” or pay for medical services at first when a worker is injured, only to later deny the claim. Therefore, if you have not received a letter from the insurance company explicitly stating your claim is accepted, it is probably not. In that case, you should contact a lawyer immediately.


Denials

When a worker seeks medical treatment for a medical condition related to employment, the insurance company will often automatically send a letter to the worker telling her that the claim is “denied” or “not compensable.” These letters are legal documents that eliminate your right to benefits you may otherwise be entitled to. If you receive a denial letter and take no action, you will not be able to appeal later. Once you receive a denial you should always call a lawyer to discuss your case. If your claim is denied, you must request a hearing to appeal your denial. If you do not request a hearing to appeal your denial, it is very unlikely you will get your claim paid. Often, workers do not realize how serious their injury is until it is too late to appeal a denial. You should always appeal your denial to preserve your rights. If you have questions about whether your claim has been denied, you should call a lawyer immediately and make an appointment for her to review your case. Consultations with workers’ compensation attorneys are free of charge.


Deferred Claims and Interim Compensation

If the insurance company does not want to accept your claim after 14 days, they can investigate it further. If they choose to investigate your claim after 14 days, they are required to pay you some benefits for medical care and time loss. If you have had medical treatment or missed work due to a work injury, and the claim has not been denied, you are probably entitled to some benefits. If you think you may be entitled to interim benefits, you should consult with a lawyer.


Recorded Statements

Employers and insurers often ask to take your recorded statement if you make a workers’ compensation claim. The purpose of these is to investigate your claim. It is very common for the employer or insurer to use information in these statements to defend a claim, i.e. to try to prove you were not injured at work. If your employer asks you for a recorded statement, you must do it because you are required by law to participate in the investigation. However, you should be sure to be prepared to answer questions about all the dates, times, names of potential witnesses, and other details of how you got injured. If you are asked to give a recorded statement, you should consult with an experienced workers’ compensation attorney.


Litigation

Once your claim has been denied and you have requested a hearing, your claim is in litigation status. The process of litigation can last up to three years. Many litigated cases are resolved much quicker. The first stage in the litigation process is a hearing. A hearing is a trial with a judge. No injured worker should attempt to litigate their claim without the assistance of an experienced workers’ compensation attorney. The process of a hearing involves many procedural rules that are too complex for a non-lawyer to navigate. You should assume the insurance company, employer, and their legal counsel are trying to win the case at all costs. Workers’ compensation, like any other litigation, is an adversarial process. You should hire an attorney if your claim is going into litigation. Oregon workers’ compensation attorneys are paid on contingency, so you will not have to pay out of pocket for representation.


Credibility Defenses

If the employer or insurance company doubts you are telling the truth about how you were injured, they will attempt to prove you are not credible. This defense is often raised when there are no witnesses to the injury, or the employer tells the insurance company it doubts you were really injured at work. Often, there is a bias against people who make workers’ compensation claims. The bias makes injured workers seem like they might be lying, and raises doubt about how a person may have been injured. An experienced lawyer should know all the tricks insurance companies use to cast doubt on your credibility. Often, providing a timely, detailed, written report of the injury to your employer can dissuade it from denying your claim on credibility grounds. If not, you should immediately consult with an experienced workers’ compensation attorney.


Independent Medical Exams

Insurers’ main weapons in litigation are independent medical exams (IMEs). An IME is a medical examination performed by an insurance company doctor. Insurance companies have a legal right to send you to their IME doctors. The purpose of these exams is to create evidence to prove you were not injured at work. Approximately 75%-85% of IME reports conclude injuries are not compensable. These doctors are paid thousands of dollars by insurance companies so they are very motivated to write negative reports about you. However, occasionally an IME doctor can write a report that helps you, so you should always be respectful, courteous, and cooperative during the exam. You should understand that everything you say to an IME doctor will be used as evidence in your case. IME doctors often misinterpret your statements in a way that makes you look bad, so think carefully about your answers to their questions. Ask them to explain their question if you do not understand what they are asking. For example, an IME doctor may ask you if your injured body part was hurt before the work incident. Does this mean immediately before the injury, or ever in your life? If you answer no, but you had an injury to that body part five years ago, they will use your answer to try to make you look dishonest. If they ask you where you are hurt, be specific. Try to avoid exaggerating or amplifying your symptoms during the examination, because IME doctors and judges often take that as a sign you are trying to take advantage of the system. An IME doctor may lightly touch the part of your body that is injured and ask if it hurts. Does this mean whether the touch itself hurts, or if that is the part of your body you hurt? Again, ask the doctor for clarification if you do not understand.


Medical Evidence for Compensability

In order to combat IMEs or other negative medical evidence, it is almost always essential to get reports from your treating physicians in support of your claim. Your attorney (sometimes with your assistance) is the person who should be responsible for producing these reports. Usually, the treating doctors support claimants. Once you get your doctor’s report signed and into evidence, you are much more likely to win your case. Above all, it is essential that you have an experienced workers’ compensation attorney to get these reports to prove your claim at hearing.


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