Santa Rosa workers compensation lawyer can negotiate with claims administrators to resolve disputes about claims and benefits
In an ideal world, when an injured worker makes a claim for a work related injury, the claim is processed quickly and correctly. The employer directs the injured worker to a clinic where medical treatment is provided at the employer’s expense. The employer’s workers’ compensation insurance company approves payment of temporary disability benefits until the injured worker is able to return to work. When the injured worker suffers permanent disability, a Qualified Medical Examiner (QME) assesses the injured worker’s impairments accurately and the claims administrator offers a fair settlement of the claim.
Unfortunately, we live in an imperfect world. When claims are disputed, a workers’ compensation lawyer can help injured workers obtain the benefits to which they are entitled. Here are some examples of common disputes and how a workers’ comp attorney helps injured workers resolve them.
Disputes About the Cause of the Injury
Employees are only entitled to workers compensation benefits if the injury and any resulting disability are work-related. In most cases, it is obvious that an employee was injured on the job. For instance, when a tool falls from a height and strikes an employee, or an employee suffers a severe shock while touching an electrical wire. In these types of events, it is obvious to everyone at the job site that the injury is work-related.
In some cases, however, employers argue that the injury was not related to the employee’s work. For example, if an employee was injured in a car accident during a lunch break while driving to perform an errand assigned by a supervisor, the employer might contend that the employee was on his or her own time. If an employee suffered a back injury during a fall at work, with no witnesses to the fall, the employer might contend that the employee was not hurt at work.
Workers compensation lawyers resolve these kinds of disputes by gathering evidence. Evidence might come from co-workers or other witnesses who may have knowledge of how the injury occurred. Medical evidence might support the injured worker’s claim rather than the employer’s theory about how the injury occurred. Workers’ compensation lawyers evaluate the evidence, advise injured workers about their odds of prevailing at a hearing with a judge and, can negotiate a favorable settlement of a disputed claim.
Disputes About Apportionment
Even if an employer concedes that an event at work caused an injury, the employer may contend that the injured worker’s disability had more than one cause. For example, suppose an injured worker has a bad knee due to a previous soccer injury. If the injured worker then falls at work, injures the knee further, and develops a permanent disability that limits climbing and squatting, part of the disability is work-related but part of it might not be. A doctor must apportion the disability to the two causes by deciding how much of the injury is attributable directly to the work injury and how much is attributable to other causes.
Doctors sometimes make mistakes when they apportion disability. For example, a doctor might identify risk factors (like age or gender) that make an employee more likely to sustain a particular injury. If a doctor apportions part of the disability to a risk factor, the injured worker should dispute that apportionment because risk factors (as opposed to actual health conditions) are not considered causes of disability. A workers compensation lawyer can help the injured worker challenge the improper apportionment so that he receives the full permanent disability benefit to which he is entitled.
Disputes About Impairment Ratings
When the treating physician determines that an injured worker will have permanent functional limitations that were caused by the work-related injury, the physician must write a “permanent and stationary” (P&S) report. The physician assesses each impairment in accordance with guidelines which have been adopted by the state. That assessment is expressed as a percentage known as Whole Person Impairment (WPI).
Injured workers sometimes disagree with their physicians’ P&S report. In particular, they may disagree with the WPI the physician assigned to their impairment. Injured workers are entitled to have another physician, a Qualified Medical Evaluator (QME) or an Agreed Medical Evaluator (AME) make an independent judgment about the correct WPI.
Workers’ compensation lawyers can help injured workers dispute findings in a P&S report by identifying potential problems with it. Workers’ comp attorneys can also advise injured workers whether it would be wise to seek a second opinion in the form of a QME and, if so, help select an appropriate one.
Disputes About Disability Ratings and Benefits
California workers’ compensation law attempts to make disability ratings objective. The rating takes into account the WPI, the injured worker’s occupation, age, and apportionment between work-related and other causes of the impairment. Still, the “correct” rating isn’t always clear. A degree of judgment is often required, particularly when the injury impairs the injured worker’s future earnings capacity.
Workers’ compensation lawyers and claims administrators often disagree about ratings and what the value of permanent disability benefit should be. Lawyers usually resolve those disputes through negotiation and settlements. When claims administrators refuse to be reasonable, Santa Rosa workers’ compensation lawyers’ present evidence to an administrative law judge and work to persuade the judge to issue a ruling that favors the injured worker.
Getting Help with Workers Compensation
Resolving disputes is the primary function of a Santa Rosa workers’ compensation attorney. If you have a dispute with a workers’ compensation claims administrator or just need advice about your workers’ compensation claim, call Kneisler & Schondel at (707) 542-5132. You can also ask us a question by submitting our online contact form.