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The Hidden Factor in Workers' Compensation Claims

September 4, 2019

 

I have been practicing workers' compensation law in Abilene, Texas for several years now. One of the more complicated issues that tends to arise in these claims is the scope of the "compensable injury."

 

The "compensable injury" is often the key to winning or losing in a workers' compensation case, because it controls virtually everything that happens over the course of the claim. 

 

In short, the "compensable injury" is any medical condition that the insurance company is obligated to cover in connection with an injured worker's case. If a medical condition is part of the "compensable injury," then the carrier is legally obligated to pay for reasonable and necessary medical treatment for that condition for the workers' lifetime. Likewise, if a medical condition is part of the "compensable injury," then the insurance company may also have to pay various forms of weekly income benefits for a certain period of time.

 

Insurance companies scrutinize an injured workers' medical records and history, and often take steps to limit the compensable injury because it limits the amount of money they have to pay on the claim. For that reason, injured workers should pay close attention to all the information that they receive from the insurance company and their doctor.

 

Things to watch out for include the following:

 

(1) A doctor says that the worker has some additional conditions that the doctor won't treat because "the insurance company won't pay for it."

(2) A doctor wants to do some testing to see if the worker has additional medical conditions, but - again - "the insurance company won't pay for it."

(3) A doctor suddenly wants to drop the worker in the middle of treatment for reasons that aren't made clear(this is often because they have gotten word from the insurance adjuster that the injury is being limited)

(4) A nurse practitioner is coming to the doctors' appointments with the worker, but seems to be advocating for the insurance company instead of the worker; often, the nurse practitioner is complaining that the insurance company hasn't accepted certain conditions that the doctor wants to treat

 

By far, however, the biggest warning sign that an injured worker may have a problem in his or her case is a form called a PLN-11. You'll know when you receive one, because - near the top of the letter in bold type will be the words "Notice of Disputed Issue(s) and Refusal to Pay Benefits" The letter will then go on to check a box which says the insurance company doesn't agree "[t]hat some of your medical conditions were caused by your work-related injury (extent of injury). Often, after checking the box, the letter will talk about things like "pre-existing conditions" that are not covered.

 

If an injured worker receives a letter like this, it is often a warning sign that the claim is headed toward trouble. If you don't act, you may not be able to get medical treatment that you need. Also, your weekly income benefits may be abruptly cut short. Even if you end up resolving the issue, if you delay in acting, it could end up taking weeks or even months to get things straightened out, and during that time you may have no income benefits or other way of supporting yourself.

 

If you run into a problem with the extent of your compensable injury, it is usually not something you can resolve on your own. It is important to reach out to an attorney who practices workers' compensation to see if they can assist you.

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