Frequently Asked Questions
When the claims adjuster makes arrangements for your medical care, the treating physician must FULLY examine you to comprehensively identify the COMPLETE extent of your work injuries. The physician must then prepare medical reports about the FULL extent of care required to properly care for ALL the consequences of your work injury. Those reports will be used to determine the nature and extent of your benefits in your case.
There may come a time when you may disagree with the kind of medical care the 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 must issue a report indicating whether you can return to work, or if you can return to work with restrictions, and for what periods of time you are so limited. The physician can report that you are temporarily unable to return to work because of your injury. At the conclusion of each of your physician appointments, the physician must provide you with a Work Status Report. You need to give a copy of the Work Status Report to your employer. If the report states that you cannot return to work, or if your employer cannot accept you with the work restrictions described in the report, the claims adjuster must pay you temporary disability benefits.
When the claims adjuster receives a physician's report requesting authorization for specific medical care, the adjuster may either immediately authorize the requested care, or the claims adjuster may send the request for authorization to Utilization Review (UR). UR involves another physician who reviews the requested medical care. UR will either certify, certify in part, or non-certify the requested care. When the care is non-certified, the claims adjuster will not authorize the requested care.
If the requested authorization for medical care is only certified in part, or it is non-certified, 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 requested the authorization; 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 to immediately challenge the UR decision. You only have 30 days to submit your challenge by facsimile or ordinary mail.
You will have to sign the Independent Medical Review Application form. Be sure to include the UR decision itself; and the physician's report. If the physician tells you the claims adjuster has denied authorization of the medical care, and the claims adjuster did not provide you with the above specific documents, you should seriously consider retaining a competent workers' compensation attorney AS SOON AS POSSIBLE.
The claims adjuster has strict deadlines to legally address physician requests for authorization for medical care, that is, to partially authorize or completely deny authorization of medical care. If the claims adjuster's response (UR decision) is LATE, a workers’ compensation judge may immediately order the medical care for which authorization was requested. However, there are many technicalities involved in successfully taking to a workers' compensation judge a challenging of a late response (late UR decision). You should seriously consider retaining a competent workers' compensation attorney to properly bring such a challenge to a workers' compensation judge.
The claims adjuster may decide to "deny" certain injured body parts or certain consequential medical conditions claiming that they are not related to your work injury. This is different from denying authorization of 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 itself is admitted. The claims adjuster will not pay the treating physician for care to any of the denied body parts or denied medical conditions. For this reason, you will need to challenge any denial of body parts or medical conditions as soon as possible. Challenging denied body parts or denied medical condition can be very complicated and time consuming. If this happens in your case, you should seriously consider retaining a competent workers' compensation attorney.
There are two types of potentially available settlements in workers' compensation cases:
1. Stipulations with Request for Award; and
2. Compromise and Release.
Preguntas Frecuentes
Hay dos tipos de resoluciones posiblemente disponibles de casos de Compensación a Trabajadores:
1. Estipulaciones con Solicitud de Orden Judicial
2. Compromiso y Liberación.
WARNING: It is a felony to make a false claim for workers' compensation benefits. This website provides important useful general information regarding workers' compensation matters. Consult an attorney to address the details of your specific case, as well as your legal rights and obligations.
ADVERTENCIA: Es una felonía hacer una falsa petición para beneficios de compensación a trabajadores. Este sitio web proporciona información general, útil e importante sobre asuntos de compensación a trabajadores. Consulte a un abogado para tratar los detalles de su caso específico, así como sus derechos y obligaciones legales.