Transcription
Hey everyone, I'm Josh Nunes with Nunes and Associates, and today I want to discuss the basics of the workers' compensation system. This is a primer; these are very basic level principles that I want to highlight, and hopefully they'll be useful to you as you move along in your workers' compensation claim.
I want to start off by giving a brief overview of what we're going to discuss today. First of all, we're going to discuss the importance of notifying your supervisor, your manager, your employer of your injury immediately after it happens. We're going to discuss the active phase of a workers' compensation claim, and we're going to discuss the permanent phase. The workers' compensation system has two phases: the active phase and the permanent phase. So, we'll discuss both of those phases today.
But first of all, I am a very visual person, so I'd like to draw a diagram, and hopefully this will aid you in your understanding of the workers' compensation claim. This here is what I call the active phase, and this here is the permanent phase.
Before you even get to discuss what benefits you're entitled to and what obligations you must follow in a workers' compensation system, you first have to get through the door. This is a door; this is called the notification door. What that means is that the workers' compensation legal system places an obligation on the injured worker to adequately and timely notify his employer of the work injury.
In other words, if you get injured and you fail to notify your employer in a reasonable time, your claim is going to get denied. So, a lot of claims die before they even enter into the system. Why? Because it was never notified.
A quick pointer here is that if you get injured on the job, make sure you notify your employer immediately. It's the law; it's required. But also, make sure you have a way to prove that you notified your employer of the injury. A lot of times what happens is we go to court, and the question that we're fighting, the issue that we're litigating, is: was this claim notified?
Of course, the client will say yes, it was notified on such and such date to such and such person, but they have no way to prove it other than their testimony. Sometimes that carries the day; sometimes you win just based on your testimony because you're a credible person. Sometimes it doesn't carry the day.
So, the better practice or the better way to achieve notification is to do it by either a written report—save a copy of the report. If you call your employer, make sure you can get phone records. If you send a text message, we can use that as proof as well.
So, very important to notify your employer and have a way to prove that you notified your employer. If you notify your employer, make sure you bring a witness with you. Make sure you write it down in a report and save a report.
Also very important is when you go to the doctor after an injury. If you go to the hospital, if you go to a clinic, let the hospital know; let the treating doctors and nurses know that you've injured yourself on the job. If a doctor includes in his report, for instance, that you've injured yourself on the job, then that is affirmative proof that you've notified your doctor of the injury, and that's important for you to get through the door.
So, let's assume you've gotten through the door. You properly notified the employer, and they agree that you notified them of the work injury. Now you've entered into the workers' compensation system.
Okay, and there's two phases: the active phase and the permanent phase. The active phase is the time frame or the phase of the workers' compensation system when doctors are trying to get you better. They're doing something medically to try to improve your condition, whether that's giving you injections, whether that's giving you medication, surgery, therapy—whatever the case may be. They are trying to improve your medical condition because you've been injured, and they want to get you to a better place.
The active phase terminates once you get to a place called MMI, which means Maximum Medical Improvement. At that point, you begin the permanent phase.
Depending on which phase you're in determines the benefits that you're entitled to. If you're in the active phase, that means that a doctor is actively treating you, actively trying to get you back to work, actively trying to get you better. Your benefits, generally speaking, are the following:
First of all, you're entitled to medical care that's reasonably related to the work injury. So, if you need surgery, you're entitled to it. If you need some kind of epidural injection, you're entitled to it. If you need medication, therapy—whatever the case may be, you're entitled to medical care. That's number one and probably the most important benefit.
Number two, you're entitled to compensation. The law says that you're entitled to 66% of your average monthly wage prior to your injury. So, if you were making $1,000 a month prior to becoming injured and you're no longer working because of the injury, you're entitled to $666.66 per month.
So, those are the two basic rights that you're entitled to. The workers' compensation system can be very litigious, meaning we can fight; we can litigate various issues in any given case. Sometimes, if a doctor recommends surgery and the insurance company hires its own doctor to say that you do not require surgery, we litigate that case. If they don't want to pay you, we'll litigate that case. If further down the road you need another surgery, that can become litigated as well.
So, sometimes in any given case, we can litigate various issues throughout the life of the case. That's why you have to make sure you understand what your rights are and be informed of what you're entitled to.
After a while, once you've received—once you've gotten through the active phase, a doctor is going to declare that you've reached what's called permanent and stationary status. You've reached MMI. This is as good as it gets. They tried to fix you; they've tried to cure you; they've tried to rehab you, and you've reached the apex. This is as good as it's going to get: Maximum Medical Improvement.
At that point, you begin the permanent phase. When you begin the permanent phase, the doctor will make three recommendations, and these three recommendations will have a significant impact on you and your life moving forward.
First of all, if you reach 100% back to normal status when you reach Maximum Medical Improvement, then congratulations! You're back to normal; you can go back to work; your life goes on as normal. That's the best-case scenario, and that's what we're looking to achieve in these cases.
But unfortunately, that's not always the case. Sometimes, when you reach Maximum Medical Improvement, you can no longer lift the weight that you could lift before. You can no longer stoop or bend over or work with your arms raised above your shoulder. And so those things lead to an impairment, and that's the kind of thing that will have a lasting effect.
So, when you reach MMI, the doctor will give three recommendations to you. The first one is something called supportive care. In essence, what that means is that moving forward, for a certain amount of time, the doctor will award you supportive care.
Supportive care is treatment—not meant to get you back to 100% status, not meant to rehab you, but simply meant to monitor your condition moving forward. Maybe that means three or four visits to the doctor per year; maybe it means a set of injections moving forward; maybe it means medication, pain medication, to help you deal with the pain that you'll have for the rest of your life. That's supportive care—not meant to fix you, so to speak, but just to give you support. That's why they call it supportive care.
So, when the doctor gives you supportive care, you have to make sure that you agree that the supportive care award is adequate. If it's not adequate, you have to speak up immediately because you only have 90 days to protest the inadequacy of the supportive care. So, that's number one.
Number two, the doctor will give you a percentage impairment rating. You'll excuse my handwriting; it's difficult to write at this angle. But in essence, what we're discussing here is the AMA guidelines. The American Medical Association provides a book called the AMA Guides, and in essence, this book determines, based on your physical or mental status, what your percentage of impairment should be.
The doctor that you go to—you have to select your doctor very carefully. First of all, you have the right to select your doctor; that's an important point to make. But when you select your doctor, your doctor must be very well-versed in the AMA Guides. They have to understand how to rate the impairment because that determines what your compensation is going to be.
So, your doctor will give you a rating. If the doctor that you have gives you a rating and you believe it's an incorrect rating, it's inadequate, then you have 90 days to protest that rating. It's very important that you are aware that this impairment rating determines a lot in terms of what your compensation is going to be.
So, once you reach MMI, let's recap: the doctor will give you a supportive care award, will give you an impairment award if you have one, and then finally, you will receive compensation based on the type of injury that you have.
This is where it gets even more complicated—maybe too complex to discuss in one short video. Maybe we'll make another video. But in essence, there are two types of compensation systems once you reach this place: scheduled injuries and unscheduled injuries.
Scheduled injuries have to do with your limbs, whether your upper extremity or your lower extremities—your legs and your arms. Based on the percentage of impairment, if you have a scheduled injury to your arms or legs, the percentage of impairment will determine what your compensation is going to be. It's as simple as that; it's black and white.
You have a 3% impairment to one of your fingers; the guides determine what your compensation is going to be. Whereas if the injury is to, say, your neck or your back, then that's not a scheduled injury; that's an unscheduled injury. There will be a loss of earning capacity analysis that is done—also very complex and a little too dense for this short video.
But in essence, once you do the loss of earning capacity analysis, that'll determine what your compensation will be per month for the rest of your life. A scheduled injury is paid for a certain amount of months depending on what the body part that was injured is. An unscheduled injury is paid per month for the rest of your life based on a loss of earning capacity analysis.
So again, I'm Josh Nunes with Nunes and Associates. Thank you for listening to this video, and we look forward to hearing from you if you have any questions.