You Have a New Workers' Compensation Claim. Are You Entitled to Benefits?

In Texas, where I practice workers' compensation law, getting a claim started is often the most challenging step. There aren't any huge barriers to starting a claim, but there are a dozen small things that can create hiccups, including inattentiveness from the carrier and the failure to fill out the right paperwork or give the correct notice. Aggressive behavior from your employer, and even passive-aggressive and microaggressive actions in the workplace, can also cause the injured worker to hesitate.

The situation is often at its worst when the employee is off work because of the injury and the employer is assuming (sometimes, in bad faith) that the reason the employee is off work has nothing to do with the job injury. Getting benefits flowing so that bills can be paid and life can continue as close to normal as possible is often a critical need for the injured worker.

If you are needing to get your workers' compensation claim moving, and aren't quite sure where to start, here are some steps you should take:

STEP ONE: Make sure your employer carries workers' compensation insurance. If not, the steps that follow won't apply to you. You'll need to look to your employer's policies and benefits plan if you need help. To check and see if your employer carries workers' compensation, you can go to this handy website.

STEP TWO: Report your workplace injury and time off to your employer in writing. If you can't make a report on paper, then put it in a text message or an email. Let your supervisor know the following in no uncertain terms: (1) that you have an injury, (2) that the injury occurred on the job, and (3) that the reason you have been off work is because of the injury. Once you have done so, ask them to submit a workers' compensation claim on your behalf. A conscientious employer who is following law should turn in your claim at this point.

STEP THREE: Submit your own claim with the Division of Workers' Compensation. Fill out this form and submit it using the instructions on the second page. Your best option is to do so at your local field office.

Now comes the most difficult part: waiting on a response from the insurance company. If your employer turns in the claim quickly, you'll often hear from the insurance company within a day or two. However, if your employer doesn't turn it in, you are going to have to wait for the Division of Workers' Compensation to send a letter to the carrier notifying it of the claim. I have seen situations where it took weeks for letters to get issued, and even longer for a response to be made to the letters. Often, insurance companies just don't acknowledge or respond to them, even though they are required to do so by law. If you get "stuck" at this stage, you may need to seek legal assistance.

In the short-term, while you are waiting for a response from the insurance company, you may need to get treated at a minor emergency clinic or an emergency room. Sometimes, documenting your condition with these types of care providers can help with the claim at a later stage.

STEP FOUR: Get set up with a doctor. Your workers' compensation carrier will tell you whether you are in or outside of a healthcare network. If you are in a healthcare network, you'll need to find a treating doctor who is part of their network. If you are outside of one, you'll need to find a treating doctor in your area who accepts workers' compensation.

STEP FIVE: Ask your treating doctor for a work status report. You can find a copy of the work status report form here. Doctors who regularly practice workers' compensation will normally know what this is. If they don't, it may be a warning sign that you need to find a different doctor.

STEP SIX: Send the work status report to your workers' compensation insurance carrier. Your doctor will usually do this for you, but when possible you should get a copy and send it immediately in order to keep things moving forward.

The work status report will indicate whether you are released to return to work at full duty or whether you have been removed from work. It may also place you on restrictions, or light duty. If you are taken off work entirely or placed on restrictions that prohibit you from doing your job, you will generally qualify for benefits. Those benefits should begin on the eighth day after you became "disabled" - i.e., unable to work due to your injury.

As you can tell, a lot of things have to happen before your benefits will start paying, and you often end up getting stuck at one stage or another. If you do, it is important not to give up. Seek help from a lawyer or at the very least ask for help from the Office of Injured Employee Counsel. In most situations, there are ways to cut the red tape and get things moving again.

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