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This guide is intended for employees who wants to know what to do if they sustain a workplace injury or illness. This article series goes beyond the moment of injury, and gives a picture of what to expect when choosing a doctor, getting treatment, and beyond. This guide is specific to California, but many of the steps described cross state lines.
This is the second part of the series covering what a worker should do in the event that they have suffered an injury or illness in the workplace. If you have recently been injured or have fallen ill due to an event or conditions at work, and have not yet filed a workers’ compensation claim with your employer, please see part 1 of this series. If you have filed a workers’ comp claim with your employer, read on.
Now that your claim has been filed with your employer, there are still steps that you must take to ensure that you receive your benefits (and partial pay for time off work, if applicable). This the beginning of your journey through the workers’ compensation system.
Once Your Claim is Accepted, or if it isn’t…
It is the business of the insurance adjuster to accept your work comp claim as legitimate. Once they do, it is time for you to find a PTP (Primary Treating Physician), who will be the doctor who examines you solely for your claim. It is important to note that your PTP is not your primary care physician, so they cannot give you medical care for anything outside of your claim.
Finding a PTP for yourself varies from business to business. Generally, either the insurance adjuster will contact you, or your employer will offer you a clinic or list of PTPs within their network. Once you have been presented with a clinic, or choice of clinics for your PTP, you must schedule an appointment with them in order to move your claim forward.
There is no specific amount of time between being given PTPs to choose from, and having your first appointment, but the longer that you wait, the more likely it is that the insurance adjuster will cancel benefits for your claim.
Following Up, and What to Expect
Once you have been assigned, or have chosen, a designated PTP for your claim, you must have follow up appointments every 45 days to continue receiving benefits.
During your appointments, the PTP will make specific examinations on the affected bodypart(s) and measure them based off of the criteria in the state’s designated workers’ comp rule set. For California, the rule set is the AMA Guides 5th Edition. The rule set has parameters for the specific body part, and gives the doctor a framework from which to measure your injury. If you injured your shoulder for example, the PTP will examine the range of motion, level of pain when moving it, etc.
Other things that the doctor will ask you about when figuring out your level of impairment from the injury are your ADLs (Activities of Daily Living). You will be asked from a set of day-to-day activities, which ones have been affected by your injury, and which are not.
Depending on your injury, you might have to get diagnostic tests performed, as well as examinations from other specialists.
It is the responsibility of you and your PTP both to give as much information as possible about the progress of your injury to make sure that you get your benefits. The insurance adjuster can refuse the treatment your doctor requested from them if they feel that your measurements were wrong or incomplete. Make sure that you tell them everything that you have been experiencing about your injury.
Do I Get to Go Back to Work?
During the course of your claim, the PTP will decide based off of the measurements described above, if you are able to return to work, and how much you are able to do there. Your injury causes what are known as ‘functional limitations’. It is the responsibility of your workplace to find a job for you that you are able to do with your injury. Sometimes you are able to do the same job, but you are not allowed to lift as much weight as before.
If you are not able to go back to work at all, you may be eligible for retraining.
Roadblocks
Workers’ comp is a complicated and deeply bureaucratic system due to regulations. The people keeping the balance are you, your PTP, your employer, and your employer’s insurance adjuster. All of these people are stakeholders in the claim. All of the stakeholders have the same goal, providing benefit and treatment as permitted by guidelines and regulations.
Each stakeholder can have an issue with the claim somewhere in the process. You, the injured worker, might have an issue with the adjuster if they are refusing treatment for your injury. You might also take issue with your PTP because you feel that they are not taking your measurements correctly. The adjuster might also take issue with your PTP for the same reason.
When this happens, one of the stakeholders may call in a workers’ comp attorney, or a QME (Qualified Medical Examiner), to try to correct the issue they have with the claim. These people brought into the claim are now considered stakeholders as well, and the dispute results in making the claim more expensive, and more drawn out.
Click here to find out more about QMEs, and if you should get one. Click here to find out about work comp attorneys, and whether you should get one.
MMI: As Good as You’re Going to Get
Some injuries or illnesses reach a full recovery, getting you back on your feet and back at your job in a certain amount of time. Unfortunately, some injuries don’t recover to 100% what they were before the injury happened. In both circumstances, there’s a point where you’re as good as you’re going to get. In workers’ comp, this is called MMI (Maximum Medical Improvement).
At this point, your PTP writes a report, known as an impairment report (PR-4), which says how much your will affect you from here on out. If the insurance adjuster agrees with the conclusion, you will receive a payout for your injury.
It Still Hurts
Your claim doesn’t necessarily end once you’ve reached MMI, though you may receive a money benefit payment when it does. If you are still in pain, your treatments and medications will move into future care, and continue indefinitely. In order for them to continue, you must continue to see your PTP for regular appointments, just as before.
Conclusion
Nobody prepares for a workplace illness or injury, much less the being thrown into the workers’ comp system.
The most simple workplace injuries have the potential to cause as many complications as severe ones when stakeholders are not performing workers’ comp correctly. By using this guide, you will be a bit better prepared for what to expect, and what to do, if it does happen to you. Be safe.
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