A Worker’s Compensation Claim from Start to Finish

 

Being hurt at work can be a traumatic experience for any Wisconsin worker. A worker can experience a lot of anxiety not only due to the fact that you have been injured, but especially when you are not able to work because of the injury. Fortunately, worker’s compensation helps most injured Wisconsin workers by providing financial benefits that helps them get through injuries to the time they can work again.

Wisconsin worker’s compensation law requires many employers to have worker’s compensation insurance, which covers the medical expenses of a work-related injury and awards an employee 2/3 of their average weekly wage for the time they are not able to work due to the injury, among other coverages.

Unfortunately, securing worker’s compensation benefits is not always as easy as simply reporting a worker’s compensation claim and getting paid. The Wisconsin worker’s compensation process can often take a long time to obtain benefits, especially when a work comp claim is denied, or in a case where an employer does not have worker’s compensation insurance.

This post explains the life of a worker’s compensation claim to help injured workers understand how their claim is likely to proceed. Worker’s compensation cases are complicated and steps vary from case-to-case, so this is a general overview of what normally occurs in these cases.

 

Step 1: The Injury

 

Imagine being at work, having a normal day and getting ready to leave for the day. As you are walking out to your car, you slip and fall on liquid just outside the building entrance. You immediately experience back pain, but think you will be able to walk it off. You leave work but after a couple of days, you start having serious pain while you work, to the point that you cannot handle the work you are doing anymore. You begin wondering what your rights are, and what you are going to do for income if you cannot work.

 

Step 2: Reporting Injury

 

The first step in a Worker’s Compensation case is to report the injury to your employer as soon as possible. It is important to do so because like in the situation above, a fall that seemed minor has turned into something more serious. The more time that passes between experiencing an injury and reporting it, the more likely an insurance company will be able to successfully claim the injury did not occur at work. Remember, a worker’s compensation insurer may not want to pay out claims, and they vigilantly scrutinize each new claim for the possibility of fraud. By reporting any injury early and thoroughly, you minimize the chance that your employer’s worker’s compensation insurer will challenge your claim, and that your worker’s compensation benefits will be delayed.

 

Step 3: Your Worker’s Compensation Claim is Approved or Denied

 

After the injury is reported, your employer is required to report the injury to its worker’s compensation insurance. From there, the worker’s compensation insurance will likely have some communications with you and can start paying the claim, but they can also deny the claim.

If your worker’s compensation claim is accepted and you start getting payments, that is great! If your claim is denied, it can put you in a difficult situation as you will have to take further steps to try to get your claim paid. A claim can be denied after it is accepted and payments are made, so although payments may start to be made to you for an injury it is not uncommon for a denial to come later.

 

Step 4: Challenging a Worker’s Compensation Claim Denial

 

If your worker’s compensation claim is denied, the next step is normally determined by the damages involved in the case and where a person is in their recovery / medical treatment.

In order to determine all the damages available in a worker’s compensation claim, an injured person has to reach what is called an “end of healing.” An end of healing is the step in the treatment where the person’s doctor determines they have reached a plateau in their improvement or, in other words, they have reached their likely maximum medical improvement. At that moment, a doctor may document a disability rating for the injury and opine on probable future treatment and prognosis of the injuries.

 

How End of Healing Affects Claim Filing

 

If a person needs continued treatment and they are able to obtain the treatment, the next step is to wait for the end of healing. Reaching an end of healing will inform the attorney of all the damages available in the case. After a worker reaches the end of healing, an attorney will gather all the records necessary to determine all the damages available and prepare an application to the department of workforce development. An application is the form that officially starts the Worker’s Compensation case with the state of Wisconsin.

When certain claims are available, an attorney may file an application to the department of workforce development BEFORE end of healing, in an effort to protect certain claims.

On the other hand, sometimes, it is impossible for people to continue treating if they do not have medical insurance. If this occurs, then an attorney may go ahead and gather all the records necessary to get ready to file an application before a person reaches an end of healing. Because future medical claims can be added to the damages requested in an application, a person may still receive the necessary treatment they need, but it may be delayed.

 

Step 5: File a Wisconsin Workers’ Compensation Claim

 

The documents necessary to file an application may differ between cases but can include:
• Medical records
• Medical Billing record
• Accident Reports
• A WKC-16-B form, where a treating physician outlines the treatment dates that the doctor saw the injured person for, diagnoses, the end of healing date, permanent limitations the person will have, whether the doctor thinks the injury was caused by the work incident, among other things
• Personnel records

 

Step 6: Negotiating with the Worker’s Compensation Insurer

 

After an application is submitted with the department and an attorney has determined the eligible damages in the case, the worker’s compensation insurer will typically negotiate with the worker’s attorney. Many cases settle in negotiations for only portion of what the claim would be worth if a hearing was held and won because of the security that a settlement can bring. For example, although a person may settle though negotiations for half of the potential worth of their case, this can bring a peace of mind because although more money could be won at a hearing, there is also the potential of losing the entire claim and getting nothing.

If a settlement cannot be reached through negotiations, then a hearing or mediation can be set for the case. At a hearing, an administrative law judge will hear the matter and determine whether she believes the worker’s compensation insurance is liable for the damages claimed by the injured worker. At a mediation, a mediator, who is a neutral person in the matter, will try to help the parties reach a settlement.

Although an administrative law judge’s decision in a hearing can often be the end of the case, either party could appeal the decision and continue the process until a determination on the appeal is decided.

 

The Worker’s Compensation Claim Process is Lengthy

 

Getting to a resolution of a worker’s compensation claim can take a very long time because various steps in the case can take months or years.

For example, the process of getting to an end of healing varies by the injury, so a very severe injury that requires multiple surgeries can cause several years to pass before a person reaches an end of healing.
The record collection process can also require a long time, as it can take months for hospitals to provide records, or for a doctor to provide an opinion, especially if they are overwhelmed with treating people.

Negotiations add more time to the process, as parties go back and forth on facts of the case, gather more information, and make propositions for settlement. When a worker’s compensation settlement is not reached in negotiations and a mediation or hearing must be set, this can add an additional several months.

Even when an injured worker gets to the hearing stage and a judge determines they are owed damages for their work-related injury, the worker’s compensation insurer can appeal the decision and this can add at least a year until a decision on the appeal is made.

 

When an Employer Does not have Worker’s Compensation Insurance

 

When an employer is required by law to have worker’s compensation insurance and they do not have it, an injured worker will make a claim against the uninsured employers fund (UEF). An injured worker can normally claim the same damages as they would with an insurance carrier, but instead of an insurance carrier being involved, a representative of the state will handle the case and determine if the employee should receive benefits. UEF then may fine the employer double the money they paid to the injured worker.

 

Legal Representation Can Help Guide You Through a Worker’s Compensation Process

 

Although there is a lot of unknown in the case and a specific timeline cannot be determined, if you have an attorney handling your worker’s compensation claim, they are the best positioned to answer questions regarding the step your case is in and the potential time it may take to reach a resolution. Reach out to your attorney with any questions specific to your case and they should be able to provide clarity on your case.

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