What is Workers' Comp?
Were you hurt at work? Wondering how you will pay your bills, how to file a claim, what’s the claim process like, and more. Well, I’m a claims adjuster so let’s examine it.
INTRO
So, you’ve been injured at work. Like any person, you likely have questions and concerns, such as “How will I pay my bills? How will I get back to being healthy again? What should I expect next?” Well I’m here to answer those questions as best I can.
Hi, I’m Michael. I’m a senior workers’ compensation claims adjuster licensed in Texas, New Hampshire, Rhode Island, and Connecticut. I’ve also handled claims in California, Connecticut, South Dakota, Missouri, Minnesota, Massachusetts, and West Virginia. I’ve worked thousands of claims since 2021 and now I’m here to help you navigate workers’ comp so be sure to subscribe for more insurance education to come.
There are three types of claims. First is called “Report Only”. This is for when you get a minor cut or burn that doesn’t require medical attention. These may seem silly but they serve a purpose of creating a paper trail for your injury. Maybe three days later, you notice the cut is red and painful. It’s now infected and requires medical treatment.
This takes us to the next type. “Medical Only.” These are claims where you require medical treatment but you haven’t been placed out of work. They’re usually pretty minor injuries but they can involve moderate medical treatment. But let’s say the antibiotics have been ineffective on your infection and you’re now facing an amputation.
That brings us to “Lost Time” or “Indemnity” claims. These are claims where your doctor has taken you out of work. They are the most complex claims and if the claim has been accepted, usually involve receiving payment for your lost time from your employer or the insurance company. Most states have a waiting period anywhere from three days to up to seven. You will only be paid for these days if you have been out of work for a set amount of time.
For example, Massachusetts currently has a five day waiting period. So, let’s say you get hurt at work on the 17th. Your first day out of work would be the 18th so this waiting period begins on the 18th and runs all the way through until the 22nd including any weekend days like Saturday and Sunday, even if you don’t normally work Saturday or Sunday. Then, you can start getting paid for your indemnity, or time off due to your injury, on the 23rd if you are still out of work.
If you’re out of work for more than 21 days, then you get paid back pay for the five day waiting period. But if you’re back to work within 21 days including weekends, the five day waiting period is not paid by the insurance company. For other states, like Rhode Island, you never get paid for the waiting period, but don’t worry, the vast majority states require insurance companies or employers to pay for this waiting period.
Now let’s discuss the claim process and what you can do to make things work more quickly. Workers’ Comp is very state specific. I plan to do videos about the various states in the future but this is meant as a basic overview.
Immediately after your injury, you should seek medical attention. Most employers will send you to an urgent care or Emergency Room based on the severity of your injury. If you go later without being sent by your employer, make sure to tell your doctor how the injury happened. Be specific. Don’t say that everything hurts because the doctor likely will not put that in the medical record. If you have a back injury but also hit your right knee, tell the doctor about it.
This is where the majority of problems between injured workers and insurance companies begin. If you only report and get treated for the back injury, when you go to get treatment for the right knee, adjusters may not approve it because they may not know about it. During initial treatment, this is not the time to be tough or hope for the best. If it hurts, mention it to the doctor.
To have your claim accepted, we need proof of any injury. This involves your doctor or the hospital sending us medical records for the date of your treatment. This may involve sensitive medical information. Your adjuster is a professional and this information will not be given or accessible to your employer. Your employer is only entitled to know your work status and expected time out of work. Pre-existing medical conditions that could affect your injury, like diabetes, high blood pressure or osteoarthritis may be mentioned in a report but other things like sexually transmitted infections, sexual orientation or other non-pertinent information will not ever be included.
Within 24 hours of receiving your claim, your claim will get assigned to an adjuster. We then contact your employer to get their side. We contact you to get your side. You don’t have to speak to us but if you don’t we have to base our decision on what your employer tells us and what the medical records say. You lose the ability to have your side heard. Your employer’s story is not given more credibility. Sometimes employers exaggerate and sometimes they outright lie. Claims adjusters know this. So it is beneficial to have your side heard by the adjuster.
From there, we make a decision on your claim. Now despite what some law firm commercials show, we do not sit there rubber stamping “DENIED” on claims. Most Workers’ Comp claims are accepted. The ones that get denied are usually for lack of medical records, a pre-existing conditions or because the injury is not work related. For example, there is a common misconception that just because something happens at work, it has to be work related. If you go to work with a pain in your side and later on your appendix bursts due to appendicitis, that’s not work related. You’d have to submit that to your medical insurance for proper coverage.
What do you do if your claim is denied? You should get a denial letter in the mail that gives you directions on how to appeal, which usually involves contacting your state’s Department of Labor.
Please subscribe to our channel for more episodes helping you navigate the often confusing world of workers’ comp. Please note that all claims and states are different so none of our videos should be taken as individual legal advice. Comment below any workers comp questions you have or click on this video to continue enjoying more videos from me, the Workers’ Comp Adjuster.
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