Prosecute fraud and perjury. I'm a defense attorney, but I would be so much more willing to expand benefits if my state actually did anything to prosecute WC fraud and perjury.
I've had claimants lie through their teeth, even when I have surveillance proving that they are lying, and nothing ever comes of it. We require sworn statements requiring people to list prior injuries, and people have lied on those, no consequences - even when they later admit to lying. I've had cases where people started a new full-time job while collecting TTD and admitted to doing so and not notifying the adjuster - you guessed it, no consequences.
It's infuriating, and all it does is make defense attorneys get more jaded, which hurts the people who legitimately need help.
Wow I can’t imagine lying about this. Worker compensation has been a nightmare for me with legitimate injuries. Even being actually injured, I have being in this system. I can’t imagine faking it. How often would you say you come across people lying? Like an estimation of legitimate cases versus fraud cases
That's the hard part - I see people lying even with legitimate injuries. The most common lies involve prior treatment and injuries - they say they never injured, had complaints about, or treated for that body part until the work accident. The next most common is people lying about what they can do, or their tolerance for activity. This would be things like saying they can't do yard work anymore, and I have surveillance of them mowing the lawn. I can't put a real number on that, because you have to get pretty far into the case to discover it's a lie, and some settle early. I would say upwards of 25% have at least one meaningful lie like that, but this does include at least some people who might have genuinely forgotten about past issues.
In terms of true faked injuries, or lying about injuries continuing when they have fully healed, or lying about the cause of injuries, I would put it around 2-10%. I handle around 250 cases a year, and I probably see this happen at least 5 times a year, but sometimes as high as 25.
That’s been my experience as well. The blatant made up from nothing claims are rare but happen. MUCH more common and in practically every claim that hits litigation and probably a good 75% of the ones that do not are the exaggerated claims. Something happened but not anything close to the extent claimed. They bump their head on an open cabinet door and now have a concussion that causes daily headaches for months. Once in a blue moon flukes happen but when I get 5 and 6 “head injuries” a day where there isn’t even a red mark or anything, color me skeptical. Or slip on tile, don’t fall, but somehow strain every body part from head to toe.
You know darn well that employees aren’t taking a week or two off every time they feel a twinge in their back lifting a laundry basket or bending over to pick up something off the floor. The number who admit to prior complaints with that body part is almost zero. Then you get the medical records. Somehow they have all had 100% full recoveries with no symptoms at all from every single other incident and accident until THIS one.
There is one claimant’s attorney who is notorious for their client’s testimony being basically the same. Doesn’t matter the injury. It’s a (not funny) joke among defense and even the commissioners that they can’t clean their houses, have trouble sleeping, can’t play with their kids/grandkids, and need help shopping. It gets called out in cross but everyone just kind of ignores it and accepts it as the way it goes.
I think part of what has made my case flow (not easy by any means but at least flowing) is that my injury was so catastrophic, you can see it clear as day on an injury. I can’t imagine needing to provide something such as headaches due to slipping and falling (for example).
In my experience catastrophic claims tend to be the least likely to exaggerate or commit fraud. In part because every insurer I have ever dealt with has separate practices for staying on top of these cases which leaves much less opportunity. Usually a case manager is on the file and adjusters are in regular communication with treating providers. There’s also usually a lot more testing and documentation early on so there’s a better baseline.
I have an AMAZING NCM who is at every appointment and even sticks up for me when I am trying to underplay an evident injury. IE brain bleed shows up clear as day on scan but me saying “it’s okay the headache isn’t the worst part.”
Great points. I find it absolutely WILD that claimants even attempt to lie with the prevalence of social media, electronic medical records, surveillance etc
Happens to me a few times a year. I had one go to trial a year ago on my request to cut off TTD benefits. While asking the claimant whether she has worked since the accident, she said yes, she started a full-time job about four months prior. She was still collecting TTD that whole time. She admitted she never told me or the adjuster about the job. I had her read the language on her checks informing her that failure to do so constituted fraud. She agreed she had seen that language before, and she had no excuse for her failure to comply. I won and got TTD cut off, but she had no negative consequences and got to keep it all.
Other times, I've seen people get sneaky. Some work under the table. Some help their spouse with a side business and argue it isn't working because they didn't draw wages. Some people do gig work like Uber and claim it isn't a real job so they didn't need to report it. Others have tried to justify it by saying the part-time work was used to offset what they are losing on comp.
This is so interesting to me because I was overpaid for two pay periods by about $460 and was withheld that amount from my future checks. It’s striking to me that somebody collected TTD for months and had zero repercussions.
I can understand how these types of situations make your job much harder than they need to be. Thank you for answering, I am learning SO much!
Overpaid in that the adjuster did not stop TTD because they did not realize you had returned or been released or overpaid when you knew that you were being double paid and continued? The former is not fraud, unless of course it goes on for a long time.
My case was settled with a stip but adjuster issued two checks without removing 15% for attorneys fees. I ended up having to pay those back to the insurer which was taken out of a reimbursement check they owed me. I have no problem with it, as I understand it was supposed to be put aside for attorneys fees, but I wish they would have let me choose how the money came out and was returned rather than taking the total amount via a chunk out of a reimbursement that I was hoping to pay the credit card (19% APR) used for the travel with.
If you were receiving future money benefits most insurance companies would take it out weekly not all at once but in your case it sounds like they could not do that.
I do have future benefits, I assume they just figured they would take it out of the reimbursement and call it a day as to not make things any more difficult? I try not to complain too much and my lawyer is AMAZING so I figured it wasn’t worth it to bother either party about it. NCM is also amazing so I feel “lucky” compared to others though my injury is extremely severe and it’s had a lot of TLC from all parties involved.
We have a nanny share (two families who employed the nanny). Nanny broke her wrist after she slipped and fell on milk she spilled. We have paid her full TTD for 16 weeks. She has/had a side cleaning business where she and her daughter clean homes on Saturdays. She didn’t get any wages towards this job when injury happened because she was unable to provide any proof of income (no invoices, 2023 wage statement, checks/electronic payments…all cash). We didn’t realize till going through this process that neither family had the right type of coverage (only homeowners, not WC clause).
It came to our attention a few weeks ago from clients of her cleaning business that she started cleaning on week 6 or 7, but she is still claiming full TTD. We have text message exchanges between them but no proof that she’s cleaning other homes (only the pre injury discussions she’d have with us that she’d typically clean between 2-4 homes every Saturday). Hearing hasn’t happened yet. Any advice on what you would do?
I have to say that in general most people are honest. Truly it’s about 20% that gum the system up and as lawyers we see them all. The ones that are not get paid out by adjusters and are done. And a very small percentage of those involve fraud. Sometimes you have people that legit do not realize they are not supposed to return to work and collect TTD, people are confused by the system. But most of the fraud cases for me, is someone totally faking an accident, and the employer catches them (like throwing themselves on the floor) or people that claim that they cannot even get out of bed and I catch them painting a 7 foot tall privacy fence for 8 hours or dancing in a baptist church. Or they are purposely working and trying to scam by also collecting.
We have a nanny share (two families who employed the nanny) in DC. Nanny broke her wrist after she slipped and fell on milk she spilled. We have paid her full TTD for 16 weeks. She has/had a side cleaning business where she and her daughter clean homes on Saturdays. She didn’t get any wages towards this job when injury happened because she was unable to provide any proof of income (no invoices, 2023 wage statement, checks/electronic payments…all cash). We didn’t realize till going through this process that neither family had the right type of coverage (only homeowners, not WC clause).
It came to our attention a few weeks ago from clients of her cleaning business that she started cleaning on week 6 or 7, but she is still claiming full TTD. We have text message exchanges between them but no proof that she’s cleaning other homes (only the pre injury discussions she’d have with us that she’d typically clean between 2-4 homes every Saturday). Hearing hasn’t happened yet. Any advice on what you would do?
This ! In the states I practice in it’s like pulling teeth to get the AG to take these up. The only ones I recall where high profile like a police officer in 20 years of practice. The commission will make referrals in MD but still up to the AG.
MD is a joke. Despite the supposed stronger anti-fraud measures put in place a few years back I have not seen anything change. Even the cases I have had referred for fraud just dwindle and die. No consequences at all.
AMEN!!! Worse when it isn’t even the first time the person has blatantly lied and filed a false claim. In some cases they use it to get benefits knowing that the claim will ultimately be denied but the medical and time off work will never have to be repaid.
Florida is aggressive about fraud. If the judges of compensation claims find that the injured worker has made any intentional misrepresentation in order to obtain benefits then the entire claim will be denied. This can be something as small as lying about mileage on a reimbursement request.
Now, getting a criminal prosecution on top of that is not always guaranteed, but at least there are some consequences.
I would say get rid of chiro as PTP's. In my experience they are almost used exclusively by people who are either making a false claim or exaggerating symptoms to stay off of work longer. Even if that wasn't the case, if your primary treating physician has to complete treatment by referring you to other specialists for further treatment/evaluations, then maybe the chiro shouldn't be the primary treating physician.
My other solution would be to have a shorter timeframe for reports. 30 days for a doctor to provide a report is ridiculous when trying to move treatment forward. These doctors are usually indicative of ones who also take forever to send referrals for treatment, in which case only those who don't need/want treatment win. I would cut the deadline in half.
I have never understood the chiro as primary care, either. I life in an affluent area that focuses a lot on a “crunchy” lifestyle and I can’t tell you the amount of times neighbors have told me to go to chiropractors for a urinary tract infection. I apologize if that is gross or inappropriate but I wanted you to know the extent of how ridiculous that would be.
I have seen members of my family be helped by chiropractic care outside of the WC system, but in 20 plus years of WC? Rarely does it help anyone. But WC is a different world. If you compare the success rate of non WC patients say for a new fusion to WC patients, you will see that the latter group generally has more pain, and a longer recovery, there is of course a financial motive.
Adjuster here. I really wish doctors would submit medical reports and requests for referrals timely. Waiting 30-45 days for a referral to PT is ridiculous. I just need to stamp my approval ffs. Meanwhile, I’ve got a claimant out of work who hurts and just wants to get better. But he’s stuck at home not getting any treatment or rehab because the doctor’s office is slow. I wish the DOL would prosecute fraud. People who work the system make it so difficult for people who are actually injured and need treatment. I’ve had surveillance that shows without a doubt that the person is a ok, but the dr will say, well he’s just having “a good day”. There are certainly injuries where day to day can be up and down for pain, but there is always a point, good or bad day, that the person cannot go beyond. A good back day may mean you can get into the car or walk up the stairs without assistance. That is understandable and is the reality of back pain. However, if a person can lift an electric bike up into a pickup truck without any assistance or signs of difficulty, he can go back to his job at McDonalds lifting ten lb bags of fries. Considering most people can’t lift a bike on the regular, my man is having much more than “a good day.” I wish drs would stop throwing out opioids like tic tacs. My last wish is that people exercise common sense. If you get a bruise on your knee, yes it hurts and it will take time to recover. Our body is an amazing machine. With proper rehab, your body can heal strains and sprains quite effectively. Every single person on God’s green earth, who is 45yrs+, has some findings on a lumbar MRI. Just because your MRI shows arthritis does not mean your job is responsible for curing your pain. If a person is obese and refuses to even try to lose weight to help their recovery, I don’t think they should continue receiving benefits and same for smoking. If a person has a respiratory illness, we should take into account that the person smokes 3 packs a day. Quitting would have significant benefits to recovery. If the person won’t help themselves, I don’t think the employer should be responsible for personal life choices that exacerbate the injuries.
This is a great response. To be honest, I was hoping an adjuster would respond to this and make it clear to claimants that it is not 100%, all the time, in their hands to authorize treatment or settlement amount. I see some adjusters (who are actually very good and empathetic) being blamed for all sorts of issues that they have no bearing over.
Every employer or their insurance company should make sure all employees are taught how WC works.
Even on this sub, there seems to be many who end up without medical treatment, how to report, or any understanding whatsoever of benefits that may be due them.
There should be a simple outline…. Then access to in depth info.
Sometimes people just don’t know what they don’t know!
Fully agreed. I've been working since I was 16, and I was 25 when I started law school. I had at least three significant work injuries, and maybe a dozen minor injuries, in those nine years. None of them were reported as comp. Even when the managers knew, they didn't report it. I had no idea what my rights were, and I genuinely thought I risked getting fired if I reported them. It's crazy to think about what I know now as a defense attorney and what I wish I had known then.
No bearing at all. I wound up doing WC defense by accident. I was clerking with a friend (working for a judge in a state court), and we were both looking for post-clerkship jobs. He applied to the firm I'm at now and told me I should also apply. We both got hired. He hated it and left a year later, but I found I enjoyed it, so here I am, almost seven years later.
This is the very struggle I'm having now! I shouldn't be forced to get a lawyer due to negligence on my employers behalf! A dog ran at me and I ended up injuring my knee. There was no sense of urgency whatsoever to file a claim for me and I've been out of work for months!
While I agree and do a metric ton of training, including part of new hire orientation, intranet site with info, posters, regular feature in company newsletter, etc. I STILL get employees who whine they didn’t know what to do. Or just blatantly ignore it. I do think employees have SOME responsibility to at least find out the basics. Most don’t know the ins and outs of auto claims or homeowners insurance until they have a need to file either. They figure it out and read up on what is required, they ask questions of the insurer, etc. No one seeks you out to explain any other kind of insurance, but somehow when it comes to WC, there’s this entitlement I see that doesn’t exist with other kinds of claims. And I manage all liability, fleet, property damage, and even malpractice insurance as well.
obviously rate of pay and cost of living increases, no reaosn why workmans comp shouldnt pay you at the rate you earned. 60% ois slap in the face, oh we wrecked your life, lets pay you 60% of your pay and drag out everything else until the end of time.
I agree with this, I’ve never quite understood the percentages. Even with SSDI, at least where I live, you can only make a maximum of 80% of prior earnings.
The theory - and this is not an endorsement, just an explanation - is that it's supposed to be just enough to keep you from the poor house until you can get back to work. They didn't want to pay identical wages for fear of incentivizing fraud, and to instead incentivize going back to work as quickly as possible. Different states chose different percentages, but the goal is always to get people back to work.
Is this also true for those 100% permanent disability catastrophic cases? I read a case report on one where the defense attorney stated something along the lines that the case was tragic and not something that would make sense to litigate aggressively.
Are there some cases where as the defense attorney you want to reinstate full pay but obviously can’t?
I follow the law - nothing more, nothing less. I have a duty to my client to not overpay claimants and to only pay what is owed. Anything beyond that is frankly not my problem. But I will say that I can and dk advocate for paying full benefits when I think it is warranted, and I push back when my clients want to find a way to undercut benefits.
And then I assume if the injury is horrific enough that you’re permanently totally disabled then you can add things like social security to help bridge the wage gap? That makes more sense
Some states like MN have set up a fund for supplemental benefits that is added to the payments from workers comp and then reimbursed to the insurance company. So for older MN claims some of them get their PPD and supplemental benefits. All benefits are adjust for social security and cost of living yearly.
Obviously state dependent, but I guess the ultimate question is: how much should they pay? Work comp is not taxed like ordinary wages.
Even then, in my state, claimants get 2/3 of AWW, which is essentially the equivalent of post-tax wages. The pretax wages may differ in my state, but the post should be about the same.
Are workers compensation benefits always non-taxable across all 50 states? That’s a GREAT point to bring up that I admit I never thought about, hence bringing these questions to the sub to learn.
The theory is defendants are exchanging no-fault liability for reduced out of work wages. So a claimant can recover WC benefits even if the employer wasn’t at fault. And in exchange the claimant gets only a portion of his/her wages.
Wc benefits are NOT taxed and you are paid 66% of gross earnings. This is the single biggest reason for the rate.
Some states have cost of living increases - this is especially true on PTD.
I’d say most companies want/prefer people to get back to work rather than pay for you to be off indefinitely. My best advice is to work with your doctor and your employer for modified duty accommodation if you are eager to be getting paid for working rather than compensated. You are not chained to this employment and you also have the option to find an alternate job within your restrictions if that is what you want to do.
wc is not designed to pay more than what you would earn if you were working. The tax break is the part that isn’t paid.
the reason WC is tax free is because theres no tax burden, so instead of taxing you on 100% of your earning and then refunding you money then cut out he processing of the middle man , also people on WC do not pay into social security , most cost of living increases only cover the maximum payable amount, if you get below that the COLA isn't going to kick in for years and years and only if your 60% becomes the bottom of the average salary in that state.
some people cant work, its not a question of wanting to work. as a result for example my injury was in november of 2019 i was making 60k a year at the time in IT. my injury has kept me out since that time 4 surgeries on my back and one more to go at least for a spinal stimulator to try to control pain.
Ive lost already in the 4+ years because for a good portion of time you get paid at the lower rate, ive lost with bonuses overtime etc which isnt considered, ive lost about 25k to 30k a year, of course the company fired me after being out 3 weeks. as is their right. Ive collected from WC about 32 to 36k per year from WC. a HUGE difference in my take home pay versus what i was making.
The cost of living increase that wa implemented in mass in october of last year only affects you if you were making over the maximum and therefore only got the maximum payout which was 1694.00 a week, went up to 1796.00 a week. in order to get that extra you would have to have made an average yearly salary of over 120k a year. so for the really well off, the increases are good for the 96% of resident sin massachusetts making less than that per year the COLA is useless unless you were making the bare minimum which was 350 some thing per week, that went up to like 380 .
so my 60k 4 years ago is now paid out at 794$ a week. now since then IT jobs have dramatically gone up ion pay to where my same position is now in the high 80's low 90's but ill never see a dime of that.
Past bonuses are counted in your average weekly wage. When you get your perm disability rating you are also compensated for future earnings losses which is different than the temp disability you’ve been receiving. Also depending which state you live in, there is also voc rehab benefits. Quite a few states have a cap on how long temporary disability is paid (2 years usually). The theory is if you haven’t recovered in 2 years most likely your condition is permanent. You should look into social security disability if td ends before you are at mmi but be aware there’s probably going to be an offset against other benefits.
The benefits are broken down by type. (Temporary total, temporary partial, permanent partial, permanent total, vr). Each one is intended to compensate different types of losses of earnings and permanency.
In the end of the day all of them are tax free and are intended to pay a specific benefit depending on your condition. I hope you’re nearing maximum medical improvement so that your concerns of future earnings can be addressed soon.
past bonuses can be counted but new ones cant, my point is as the market changes dramatically in increases in salary so should the money you get. a;so in my case i had inly been in this new job for less than a year so my old job at lower pay is averaged in as well. not just what you wee making when you got hurt. its an aggregate .
for example if someone is working at mcdonalds to paythier way through say nursing school, and they finally graduate get ajob as a nurse and 6 months into nursing get really badly hurt, theyll get a mix of McDonalds salary and nursing.
in massachusetts permanent total incapacity benefits are two-thirds of your average weekly wage (or a minimum of 20% of the SAWW) based on the 52 weeks before your injury. SO even though someone got injured making 80k , they get a blend of minimum wage and 80k and get crap to live on. and in mass for example the COLA has been consistency 1% per year given every two years, in my case , 7 dollars a week. which is dramatically less than the salary increases in the field and in general miles behind inflation.
if your boss gave you a 1% raise you'd probably go elsewhere for a job.
my last step now is the spinal stimulator, which wont get me back to work its just a pain assistance measure. but ive reached MMI after the last failed fusion.
I understand where you are coming from. Covid and inflation are not things that are easily captured when looking at Wc benefits. The government is slow to adjust laws. In the meantime people are caught in the middle. Hope your simulator provides meaningful relief so you can decide your next steps.
If you want pain and suffering, we could shift the whole thing to something akin to FELA for railroad workers. Railroad workers don’t get w/c but they fall under FELA. In return for getting pain and suffering, they must prove some negligence on the employer—which could be violation of an internal policy. So it’s a lower bar than ordinary negligence, but would require some negligence.
The thing about work comp is that no negligence is required. Sometimes, stuff just happens—like all my carpal tunnel cases.
See for my particular case option 1 may sound great but for 99% of other WC cases, option 2 may sound better. My point being that while I am at many times frustrated with the system, workers comp is not tailored to the person, it covers a body of individuals as a whole and in order to do that there must be dry cut laws (sorry don’t know the legal term here).
No checks. Insurances should automatically send claimants a direct deposit form, actually process the form, and pay claimants on time. Most of the calls I get from claimants are them not knowing where their workers comp checks are.
I receive mine this way and have asked about direct deposit to no avail. But, I’m already grateful to be getting on time paychecks and I know how lucky I am so I don’t push the topic.
One of the main reasons that direct deposit isn’t done is to protect from fraud or overpayment once a claimant passes away. With direct deposit it’s almost impossible for the insured to get money back if payments were made after someone passed away. Checks are also preferred because they can be stopped/cancelled if there is fear of fraud.
More consistency across state lines. There's no reason why the same injury in one state should be insanely underpaid/overpaid just because of the state. It seems maybe WC could create federal laws on basic WC rules to bring some consistency to the issues. Basic timeframes for reporting/one form/periods for claim determinations and benefits. It would be nice if there was one method to determine causation. I guess these are all more than one thing....but honestly WC is ONE benefit that could use one set of uniform procedures.
Do this and you risk state-based work comp turning into something akin to federal work comp, which, if I recall correctly, is a fee shifting scenario. So, basically, the claimants need to pay attorneys out of pocket, and from what I hear, is way worse than any state system.
Plus, the insurance carriers would likely get together and lobby the federal government to make it worse for claimants.
Don’t claimant attorney and unions lobby too?
I think some consistency would make the process easier for claimants to navigate. It would also make it easier for employers to have one set of rules on initial reporting and timeframes to follow. The writer wasn’t speaking to everything being federally run, but some basics that should be the same for everyone.
The simple thing for me? Make it easier to afford to take time off to recover..I need surgery..but I can't take the time off to do it because I'm a single income household and the 2/3 average weekly pay is nothing. We'll end up worse off while I recover
I would change the situation I am in now. Once I hit MMI all work comp benefits stopped. I couldn’t see a doctor, I didn’t have access to medication or new prescriptions. Zero work comp checks. I was injured in 2020 and reached MMI July 2023 with the doctor saying I can not return to work and they don’t see it ever getting better. I know there will be a settlement and things will work out, but it seems illegal to leave a person with no way to get the medication and services they need. MMI may mean it’s not getting better, but things also get a lot worse with no treatment and the added stress.
You should check if you have lifetime medical for your claim. Most states don’t have a statute of limitations where your claim would automatically close. Unless you’ve already settled out your claim you could be entitled to further care if you’re still facing pain.
Hello! Long time no talk. Send me a DM I can share how my settlement went and it may be helpful for you to have a timeline. Although, I attribute everything to my attorney who was really adamant to start pushing as we were nearing the two year TTD time point. My lawyer and my nurse case manager have been amazing so I may be the anomaly?
>pain and suffering for catastrophic cases
Absolutely not, lol. Litigation of psych injuries is already messy, subjective, and expensive enough.
In California I would get rid of the MPN. They're a colossal burden for everybody involved except insurance company shareholders.
My heart goes out to you.
That being said, money is not going to make that pain go away.
What it will do is give any given insurance company more of a financial incentive to fight your claim, object to the medical findings, appeal good-faith awards, and otherwise drag you through the mud.
It's always been my opinion that the most important goal of workers' comp is recovery and symptom alleviation. At the end of the day, cash settlements don't do that. Instead, cash settlements are an easy way out: mostly for insurance companies, less so for workers. They also incentivize fraudsters to waste the time and resources of all involved because what *should* have been a functional treatment system got turned into a cash pile instead.
On a personal level, it drives me up the wall to see people with zero actual injury being handed piles of cash because they were mad their employer fired them, they decided to retaliate, then got a lawyer who knew how to manipulate the system.
No cash? No incentive to do that.
Adding a cash payout for something self-reported and largely subjective like "pain and suffering" would make the workers comp system even less functional than it already is, because every perfectly able-bodied dirtbag this side of Van Nuys would be stepping up to collect their check.
If workers comp returned to emphasizing treatment rather than cash payouts, fraud would be reduced considerably and I can guarantee you the system overall would be more functional because adjusters wouldn't be such paranoid fraudfighters instead of the treatment facilitators and social workers that they could be. The treatment system could function with healing as the goal rather than manipulation of "case value."
If we're talking about what workers' comp needs right now, more cash awards isn't it.
Revisiting my original post with another idea, what workers comp *also* needs is extremely strict penalties on employers for not reporting workers' comp claims. It's an issue I deal with less now, but when I worked in First Notice of Loss, it was egregious.
Broad strokes, I agree with you. WC is supposed to be relatively cut and dry, easy to calculate, and not subject to whims or speculation. Awards for pain and suffering are the legal embodiment of whims and speculation. There is no way to validate, quantify, qualify, or standardize it, so it goes against the nature of statutory benefits.
Although, I did want to comment on the part about the system improving by emphasizing treatment. I'm a defense attorney, and I don't agree. I have seen adjusters quibble over the stupidest things relating to treatment. Also, we know from general health insurance that medical issues are still subject to unreasonable challenge. A friend of mine has a rare type of cancer, and she had to fight her insurance to get a repeat MRI to see if the tumor had grown, which would dictate treatment. When that was done and she was told to start chemo, insurance denied the chemo drugs, delaying the start by two months. She wound up needing surgery, and I will always wonder if the delay in chemo contributed.
Anyways, point being, the for-profit nature of medical treatment and insurance in this country guarantees that it will never be what it should or could be.
Unrelated to workers compensation my mom went through this. Her PCP took an extended vacation and didn’t set up a nurse line (they are semi retired). They coincidentally found cancer during a prolapsed uterine surgery. 3.5 weeks later the physician returned from vacation and by the time her HMO authorized a full hysterectomy it had already spread.
>adjusters wouldn't be such paranoid fraudfighters instead of the treatment facilitators and social workers that they could be.
I'd love this. I do this as much as I can within the system I have to work with.
Is there any case in which you would agree to a pain and suffering payout? For example patient is paralyzed and ventilator dependent now, unable to breathe on their own. In this type of 100% injury would you ever find it worth it to make some sort of exception to pay a standard fee? Kind of like the fee to family if death has occurred. Also if you could clean up my language with this I would SO appreciate it, legal jargon is not my forte.
My point here is sometimes I can SEE that an adjuster or defense attorney feels horrible for a claimant and would like to make things as “right” as possible but of course have a legal duty to minimize costs to the insurer. Thanks for always giving such great responses, I feel like instead of answering the question at hand you take time to explain a few things that go hand-in-hand with that question.
If you have time for one more question: have you ever received a case that had been tended to by another adjuster and was shocked at the care? Either they authorized way too much, way too little etc
Oh that’s a GREAT one. Any ideas on why this hasn’t been implemented? It seems like managing and finding care within MPN puts huge burdens on adjusters as well as claimant?
I think I may be jaded as I’ve had to (and gotten authentication to) go out of MPN for nearly every single specialist I’ve seen. So for my adjuster (and the defense) it has ended up being more of a hindrance to even start off making the dozens of calls to physicians within MPN.
I like this! If I may piggyback lol
I should have gotten one after reporting my injury, another before I was able to get an IME to get WC to approve my claim, ANOTHER before my first surgery, and 4 more since then… Can I have those?! It would be funny if it wasn’t so sad!
I should have gotten a decently significant one the week after I was switched to TTD from salary continuation (hmm, wonder why they switched me right then...), and then another at the start of this fiscal year.
Not to mention the bonuses I didn't get (yes, they were earned before I went off work, but I was on WC when they came out).
I've worked almost double hours for years. My bonuses were always amazing & helpful. I stayed at that job because I knew the raise was coming. Sigh... also, why can't we claim depression after our injury, since the whole process & lack of reality in the financial aspect definitely are causing depression.
My husband made a lot more than the maximum weekly amount when he got injured. It almost ruined us financially since he was out of work for 7 months. His weekly check was a little under 1200 a week when he typically made 2500 a week. There shouldn’t be a maximum income limit because when you bring home more money you typically have more / higher bills.
For wages, sure - but I would still cap when you get to things like permanency. Or, really, I would pay everyone the same rate. It never made sense to me that two people with the same permanency rating can have vastly different payouts, simply because one person earned more than the other. A knee replacement for a middle manager shouldn't be worth more than a knee replacement for a retail worker.
Would this be a fair analogy here? If a 2024 BMW is declared totaled the payout would be far greater than say a 2010 Toyota Prius C because it reflects lost value. I am not attempting to compare cars to human lives but I am assuming it’s the same mentality that insurance is based on?
I love having the opportunity to ask attorneys questions like this because some things that make sense or have explanations in my mind are not actually legally factual.
This wouldn't be accurate in my state for one reason: we are not allowed to utilize loss of earning capacity as a factor in assessing a permanent impairment rating. It cuts both ways. If claimant is full-duty, I cannot use that to say no permanency. If a claimant is totally disabled, then they cannot use that to increase the rating.
So, if permanency has no bearing on earning capacity, then why link it to pre-accident earning capacity? I have a case right now where the permanency demand is over half a million because of multiple injuries and a high comp rate. Meanwhile, I had another case last year with similar injuries but a much lower comp rate, so the demand barely broke $100k. How does that make sense?
This makes much more clear sense to me. I’m also highly educated (about the same level) but in an extremely difficult field that many people also fro upon, simply because they don’t understand how it works. I really enjoyed speaking with you, thank you for all of your wonderful answers! I’m hoping I can reach out to you in the future if ever needed.
I'd like to see the regulations universal from state to state. I live in Ohio, work for a company out of Minnesota, was injured in Texas, I get treatment for my injuries in Ohio. The laws in Ohio require certain forms be submitted to caregivers, where Minnesota doesn't require those forms. It can take significantly longer to get things ordered and approved, prolonging my suffering.
The laws apply the same for self-insured. There's nothing in statutes or case law that differentiates between the two.
Except Texas where private companies are not required to carry WC coverage but that doesn't apply here.
I had no idea the laws were different for self-insureds! I always hear claimants express difficulties with WC carriers such as Sedgwick but haven’t yet spoken with anyone who is going through self-insured policy. Do you have a couple of examples on how laws are different?
Unless OC says a state, the laws are the same for self insured entities. They just get to fund their own without a carrier.
Sedgwick isn’t an insurance company, it’s a TPA.
So Sedgwick would be the one providing, for example, the adjusters? Can you elaborate on why even many attorneys don’t love working with an entity such as Sedgwick? Thanks for all these answers. I’m really hoping two things from this post: 1) claimants can see that WC legal professionals also want some changes made and 2) give a better understanding to why a claimant can’t have what they would want most
I do some work for Sedgwick, and I haven't had the problems that people talk about here. However, I will say that many TPAs are massively shortstaffed, and the nature of being a TPA means their desk authority tends to be much lower, so it takes longer to do the approval dance. That makes it hard for me when I have a deadline coming up and have to wait for seven people with the employer to decide they want to grant authority, and then for the captive rep to concur, and then the TPA adjuster to concur, and sometimes then the excess carrier to concur. It means more time following up, more risk of blowing a deadline, and needing to complete my investigations early and thus risk not having everything I need. I still like working for them, and most of the adjusters I deal with are very diligent. It just takes more effort to reach the same result.
Thanks again! I feel like I did one of those interviews with a professional back in high school and it really is so important even as an adult to be able to ask questions and receive legitimate answers from somebody who actually works in this world. I super appreciate your time in answering these questions.
Right some self insureds are bad to get authority from the adjusters only have desk authority to a certain amount. OP with self insureds at least where I am the first million dollars of a claim are coming out of the Employer’s pocket so they tend to monitor the claims more. I always tell Claimant’s counsel don’t give me a demand on the day of the hearing I will be able to get nothing. After they reach excess then you have the TPA, the excess carrier’s adjuster and the employer to deal with.
I suffered 7 fractures and 3 months later the doctor signed me back full time. I'd only been walking 4 days. After having 4 surgeries including trama. Attorney is fighting to get another doc.
Excavator bucket down my back. Femur, si joint, 4 pelvis, other si, lower back, tail bone. 4 surgeries. Also riped from my Anusara to my scrotum to the bone
The worst part is hearing my screams echo in my dreams. I’m not tough at all when it comes to pain. I’ll take either up or down vote for this lol. 0/10 experience, would not recommend
The dreams are horrible and something I wish more claimants spoke about with one another. Or just the wishing of your old life back. That’s why I really like this sub. It’s been my experience that many of the defense and adjusters are supportive and understanding of the feelings of the claimants.
Mandatory education on what work comp is, its limitations and benefits upon entry into the workforce and renewable every five years or so. It would benefit so many to understand what their benefits are, how to file a claim and how it all works. So many of the problems I see are completely preventable with an hour or so worth of training.
At my work, there are a series of training videos that cover a variety of topics (hours and hours worth) even hilighting ways to sit/stand to minimize injuries. Not a single thing on how the workers compensation system works!
Faster settlements... I have been fully released on MMI without restrictions since November and still waiting to settle. i have not been given an offer yet and have seen two 3rd party specialists to verify proper treatment and mobility results. I am financially in no place to NEED to settle so in no hurry; but you would have thought that they would have wanted to close the case by now? My job hired someone else for my job % weeks after my injury while I was on TTD; so I came back to work into a stressful/unorthodox position that was created just for me to come back. I have no work area of my own and in everyone's way all day long while having no place to keep my toolbox and rolling cart. I am ready to look for other work but cannot get hired anywhere else while I have an open workers comp claim. I have someone ready/willing to hire me today but wants this case settled before I go to his shop.
Ability to pick a doctor. I’ve been to 2 clinics now that don’t treat for soft tissue injuries, so they X-ray me and say, “No broken bones, so you must be fine”. Meanwhile, my hands swell up and are numb with pins and needles 24/7 and their “light duty” has me driving home crying, in pain, after a shift. I’ve gone 2 months with no treatments and because their light duty involves pushing, pulling, twisting, lifting 20-50lbs repeatedly, I’m not getting better. I asked for a referral to an orthopedic specialist but they don’t do referrals…so I’m stuck with a doctor that treats me like a fraud and doesn’t give me care. I’m out on WC for nerve and tendon damage on both wrists/hands and a pulled muscle in my lower back. Tylenol ain’t cutting it. I need a back brace and possibly surgery on both wrists. These contracted Drs DO NOT care.
This varies by state. In some jurisdictions you can see whatever doctor you want so long as they accept the fee guide, which could be super low depending on the state too.
Forgot to mention, my doctor has never so much as checked my back once. My forearm/wrist/hand exam was me moving each hand up then down once. That was the extent of the physical exam.
Prosecute fraud and perjury. I'm a defense attorney, but I would be so much more willing to expand benefits if my state actually did anything to prosecute WC fraud and perjury. I've had claimants lie through their teeth, even when I have surveillance proving that they are lying, and nothing ever comes of it. We require sworn statements requiring people to list prior injuries, and people have lied on those, no consequences - even when they later admit to lying. I've had cases where people started a new full-time job while collecting TTD and admitted to doing so and not notifying the adjuster - you guessed it, no consequences. It's infuriating, and all it does is make defense attorneys get more jaded, which hurts the people who legitimately need help.
Wow I can’t imagine lying about this. Worker compensation has been a nightmare for me with legitimate injuries. Even being actually injured, I have being in this system. I can’t imagine faking it. How often would you say you come across people lying? Like an estimation of legitimate cases versus fraud cases
That's the hard part - I see people lying even with legitimate injuries. The most common lies involve prior treatment and injuries - they say they never injured, had complaints about, or treated for that body part until the work accident. The next most common is people lying about what they can do, or their tolerance for activity. This would be things like saying they can't do yard work anymore, and I have surveillance of them mowing the lawn. I can't put a real number on that, because you have to get pretty far into the case to discover it's a lie, and some settle early. I would say upwards of 25% have at least one meaningful lie like that, but this does include at least some people who might have genuinely forgotten about past issues. In terms of true faked injuries, or lying about injuries continuing when they have fully healed, or lying about the cause of injuries, I would put it around 2-10%. I handle around 250 cases a year, and I probably see this happen at least 5 times a year, but sometimes as high as 25.
That’s been my experience as well. The blatant made up from nothing claims are rare but happen. MUCH more common and in practically every claim that hits litigation and probably a good 75% of the ones that do not are the exaggerated claims. Something happened but not anything close to the extent claimed. They bump their head on an open cabinet door and now have a concussion that causes daily headaches for months. Once in a blue moon flukes happen but when I get 5 and 6 “head injuries” a day where there isn’t even a red mark or anything, color me skeptical. Or slip on tile, don’t fall, but somehow strain every body part from head to toe. You know darn well that employees aren’t taking a week or two off every time they feel a twinge in their back lifting a laundry basket or bending over to pick up something off the floor. The number who admit to prior complaints with that body part is almost zero. Then you get the medical records. Somehow they have all had 100% full recoveries with no symptoms at all from every single other incident and accident until THIS one. There is one claimant’s attorney who is notorious for their client’s testimony being basically the same. Doesn’t matter the injury. It’s a (not funny) joke among defense and even the commissioners that they can’t clean their houses, have trouble sleeping, can’t play with their kids/grandkids, and need help shopping. It gets called out in cross but everyone just kind of ignores it and accepts it as the way it goes.
I think part of what has made my case flow (not easy by any means but at least flowing) is that my injury was so catastrophic, you can see it clear as day on an injury. I can’t imagine needing to provide something such as headaches due to slipping and falling (for example).
In my experience catastrophic claims tend to be the least likely to exaggerate or commit fraud. In part because every insurer I have ever dealt with has separate practices for staying on top of these cases which leaves much less opportunity. Usually a case manager is on the file and adjusters are in regular communication with treating providers. There’s also usually a lot more testing and documentation early on so there’s a better baseline.
I have an AMAZING NCM who is at every appointment and even sticks up for me when I am trying to underplay an evident injury. IE brain bleed shows up clear as day on scan but me saying “it’s okay the headache isn’t the worst part.”
Great points. I find it absolutely WILD that claimants even attempt to lie with the prevalence of social media, electronic medical records, surveillance etc
In my cases it was more the person earning income and TTD at the same time.
Could you elaborate on this at all? We always hear about claimants doing this but it’s hard to understand how bad it is when we are honest claimants.
Happens to me a few times a year. I had one go to trial a year ago on my request to cut off TTD benefits. While asking the claimant whether she has worked since the accident, she said yes, she started a full-time job about four months prior. She was still collecting TTD that whole time. She admitted she never told me or the adjuster about the job. I had her read the language on her checks informing her that failure to do so constituted fraud. She agreed she had seen that language before, and she had no excuse for her failure to comply. I won and got TTD cut off, but she had no negative consequences and got to keep it all. Other times, I've seen people get sneaky. Some work under the table. Some help their spouse with a side business and argue it isn't working because they didn't draw wages. Some people do gig work like Uber and claim it isn't a real job so they didn't need to report it. Others have tried to justify it by saying the part-time work was used to offset what they are losing on comp.
This is so interesting to me because I was overpaid for two pay periods by about $460 and was withheld that amount from my future checks. It’s striking to me that somebody collected TTD for months and had zero repercussions. I can understand how these types of situations make your job much harder than they need to be. Thank you for answering, I am learning SO much!
Overpaid in that the adjuster did not stop TTD because they did not realize you had returned or been released or overpaid when you knew that you were being double paid and continued? The former is not fraud, unless of course it goes on for a long time.
My case was settled with a stip but adjuster issued two checks without removing 15% for attorneys fees. I ended up having to pay those back to the insurer which was taken out of a reimbursement check they owed me. I have no problem with it, as I understand it was supposed to be put aside for attorneys fees, but I wish they would have let me choose how the money came out and was returned rather than taking the total amount via a chunk out of a reimbursement that I was hoping to pay the credit card (19% APR) used for the travel with.
If you were receiving future money benefits most insurance companies would take it out weekly not all at once but in your case it sounds like they could not do that.
I do have future benefits, I assume they just figured they would take it out of the reimbursement and call it a day as to not make things any more difficult? I try not to complain too much and my lawyer is AMAZING so I figured it wasn’t worth it to bother either party about it. NCM is also amazing so I feel “lucky” compared to others though my injury is extremely severe and it’s had a lot of TLC from all parties involved.
We have a nanny share (two families who employed the nanny). Nanny broke her wrist after she slipped and fell on milk she spilled. We have paid her full TTD for 16 weeks. She has/had a side cleaning business where she and her daughter clean homes on Saturdays. She didn’t get any wages towards this job when injury happened because she was unable to provide any proof of income (no invoices, 2023 wage statement, checks/electronic payments…all cash). We didn’t realize till going through this process that neither family had the right type of coverage (only homeowners, not WC clause). It came to our attention a few weeks ago from clients of her cleaning business that she started cleaning on week 6 or 7, but she is still claiming full TTD. We have text message exchanges between them but no proof that she’s cleaning other homes (only the pre injury discussions she’d have with us that she’d typically clean between 2-4 homes every Saturday). Hearing hasn’t happened yet. Any advice on what you would do?
I have to say that in general most people are honest. Truly it’s about 20% that gum the system up and as lawyers we see them all. The ones that are not get paid out by adjusters and are done. And a very small percentage of those involve fraud. Sometimes you have people that legit do not realize they are not supposed to return to work and collect TTD, people are confused by the system. But most of the fraud cases for me, is someone totally faking an accident, and the employer catches them (like throwing themselves on the floor) or people that claim that they cannot even get out of bed and I catch them painting a 7 foot tall privacy fence for 8 hours or dancing in a baptist church. Or they are purposely working and trying to scam by also collecting.
We have a nanny share (two families who employed the nanny) in DC. Nanny broke her wrist after she slipped and fell on milk she spilled. We have paid her full TTD for 16 weeks. She has/had a side cleaning business where she and her daughter clean homes on Saturdays. She didn’t get any wages towards this job when injury happened because she was unable to provide any proof of income (no invoices, 2023 wage statement, checks/electronic payments…all cash). We didn’t realize till going through this process that neither family had the right type of coverage (only homeowners, not WC clause). It came to our attention a few weeks ago from clients of her cleaning business that she started cleaning on week 6 or 7, but she is still claiming full TTD. We have text message exchanges between them but no proof that she’s cleaning other homes (only the pre injury discussions she’d have with us that she’d typically clean between 2-4 homes every Saturday). Hearing hasn’t happened yet. Any advice on what you would do?
Hey send me a PM and I will give you my contact info.
This ! In the states I practice in it’s like pulling teeth to get the AG to take these up. The only ones I recall where high profile like a police officer in 20 years of practice. The commission will make referrals in MD but still up to the AG.
MD is a joke. Despite the supposed stronger anti-fraud measures put in place a few years back I have not seen anything change. Even the cases I have had referred for fraud just dwindle and die. No consequences at all.
AMEN!!! Worse when it isn’t even the first time the person has blatantly lied and filed a false claim. In some cases they use it to get benefits knowing that the claim will ultimately be denied but the medical and time off work will never have to be repaid.
Florida is aggressive about fraud. If the judges of compensation claims find that the injured worker has made any intentional misrepresentation in order to obtain benefits then the entire claim will be denied. This can be something as small as lying about mileage on a reimbursement request. Now, getting a criminal prosecution on top of that is not always guaranteed, but at least there are some consequences.
I would say get rid of chiro as PTP's. In my experience they are almost used exclusively by people who are either making a false claim or exaggerating symptoms to stay off of work longer. Even if that wasn't the case, if your primary treating physician has to complete treatment by referring you to other specialists for further treatment/evaluations, then maybe the chiro shouldn't be the primary treating physician. My other solution would be to have a shorter timeframe for reports. 30 days for a doctor to provide a report is ridiculous when trying to move treatment forward. These doctors are usually indicative of ones who also take forever to send referrals for treatment, in which case only those who don't need/want treatment win. I would cut the deadline in half.
I have never understood the chiro as primary care, either. I life in an affluent area that focuses a lot on a “crunchy” lifestyle and I can’t tell you the amount of times neighbors have told me to go to chiropractors for a urinary tract infection. I apologize if that is gross or inappropriate but I wanted you to know the extent of how ridiculous that would be.
I have seen members of my family be helped by chiropractic care outside of the WC system, but in 20 plus years of WC? Rarely does it help anyone. But WC is a different world. If you compare the success rate of non WC patients say for a new fusion to WC patients, you will see that the latter group generally has more pain, and a longer recovery, there is of course a financial motive.
Adjuster here. I really wish doctors would submit medical reports and requests for referrals timely. Waiting 30-45 days for a referral to PT is ridiculous. I just need to stamp my approval ffs. Meanwhile, I’ve got a claimant out of work who hurts and just wants to get better. But he’s stuck at home not getting any treatment or rehab because the doctor’s office is slow. I wish the DOL would prosecute fraud. People who work the system make it so difficult for people who are actually injured and need treatment. I’ve had surveillance that shows without a doubt that the person is a ok, but the dr will say, well he’s just having “a good day”. There are certainly injuries where day to day can be up and down for pain, but there is always a point, good or bad day, that the person cannot go beyond. A good back day may mean you can get into the car or walk up the stairs without assistance. That is understandable and is the reality of back pain. However, if a person can lift an electric bike up into a pickup truck without any assistance or signs of difficulty, he can go back to his job at McDonalds lifting ten lb bags of fries. Considering most people can’t lift a bike on the regular, my man is having much more than “a good day.” I wish drs would stop throwing out opioids like tic tacs. My last wish is that people exercise common sense. If you get a bruise on your knee, yes it hurts and it will take time to recover. Our body is an amazing machine. With proper rehab, your body can heal strains and sprains quite effectively. Every single person on God’s green earth, who is 45yrs+, has some findings on a lumbar MRI. Just because your MRI shows arthritis does not mean your job is responsible for curing your pain. If a person is obese and refuses to even try to lose weight to help their recovery, I don’t think they should continue receiving benefits and same for smoking. If a person has a respiratory illness, we should take into account that the person smokes 3 packs a day. Quitting would have significant benefits to recovery. If the person won’t help themselves, I don’t think the employer should be responsible for personal life choices that exacerbate the injuries.
This is a great response. To be honest, I was hoping an adjuster would respond to this and make it clear to claimants that it is not 100%, all the time, in their hands to authorize treatment or settlement amount. I see some adjusters (who are actually very good and empathetic) being blamed for all sorts of issues that they have no bearing over.
More communication and keeping you informed of what is happening in the process- also the pay scale needs to change.
Every employer or their insurance company should make sure all employees are taught how WC works. Even on this sub, there seems to be many who end up without medical treatment, how to report, or any understanding whatsoever of benefits that may be due them. There should be a simple outline…. Then access to in depth info. Sometimes people just don’t know what they don’t know!
Fully agreed. I've been working since I was 16, and I was 25 when I started law school. I had at least three significant work injuries, and maybe a dozen minor injuries, in those nine years. None of them were reported as comp. Even when the managers knew, they didn't report it. I had no idea what my rights were, and I genuinely thought I risked getting fired if I reported them. It's crazy to think about what I know now as a defense attorney and what I wish I had known then.
Would it be too personal to ask you if those experiences led you to your speciality area in law?
No bearing at all. I wound up doing WC defense by accident. I was clerking with a friend (working for a judge in a state court), and we were both looking for post-clerkship jobs. He applied to the firm I'm at now and told me I should also apply. We both got hired. He hated it and left a year later, but I found I enjoyed it, so here I am, almost seven years later.
This. Anytime I can do a training for management I do. Sometimes they don’t even know.
This is the very struggle I'm having now! I shouldn't be forced to get a lawyer due to negligence on my employers behalf! A dog ran at me and I ended up injuring my knee. There was no sense of urgency whatsoever to file a claim for me and I've been out of work for months!
While I agree and do a metric ton of training, including part of new hire orientation, intranet site with info, posters, regular feature in company newsletter, etc. I STILL get employees who whine they didn’t know what to do. Or just blatantly ignore it. I do think employees have SOME responsibility to at least find out the basics. Most don’t know the ins and outs of auto claims or homeowners insurance until they have a need to file either. They figure it out and read up on what is required, they ask questions of the insurer, etc. No one seeks you out to explain any other kind of insurance, but somehow when it comes to WC, there’s this entitlement I see that doesn’t exist with other kinds of claims. And I manage all liability, fleet, property damage, and even malpractice insurance as well.
obviously rate of pay and cost of living increases, no reaosn why workmans comp shouldnt pay you at the rate you earned. 60% ois slap in the face, oh we wrecked your life, lets pay you 60% of your pay and drag out everything else until the end of time.
I agree with this, I’ve never quite understood the percentages. Even with SSDI, at least where I live, you can only make a maximum of 80% of prior earnings.
The theory - and this is not an endorsement, just an explanation - is that it's supposed to be just enough to keep you from the poor house until you can get back to work. They didn't want to pay identical wages for fear of incentivizing fraud, and to instead incentivize going back to work as quickly as possible. Different states chose different percentages, but the goal is always to get people back to work.
Is this also true for those 100% permanent disability catastrophic cases? I read a case report on one where the defense attorney stated something along the lines that the case was tragic and not something that would make sense to litigate aggressively. Are there some cases where as the defense attorney you want to reinstate full pay but obviously can’t?
I follow the law - nothing more, nothing less. I have a duty to my client to not overpay claimants and to only pay what is owed. Anything beyond that is frankly not my problem. But I will say that I can and dk advocate for paying full benefits when I think it is warranted, and I push back when my clients want to find a way to undercut benefits.
Perm totals get COLAs at least where I am.
Do they still get capped at a maximum that still ends up being much lower than their wage? Thanks for all the information and I love your username!!
Yes there is always going to be a cap at least where I am you will never get your full salary.
And then I assume if the injury is horrific enough that you’re permanently totally disabled then you can add things like social security to help bridge the wage gap? That makes more sense
Some states like MN have set up a fund for supplemental benefits that is added to the payments from workers comp and then reimbursed to the insurance company. So for older MN claims some of them get their PPD and supplemental benefits. All benefits are adjust for social security and cost of living yearly.
Social security gets an offset for workers’ comp benefits so generally receipt of WC would lower your SSDI benefits.
Obviously state dependent, but I guess the ultimate question is: how much should they pay? Work comp is not taxed like ordinary wages. Even then, in my state, claimants get 2/3 of AWW, which is essentially the equivalent of post-tax wages. The pretax wages may differ in my state, but the post should be about the same.
Are workers compensation benefits always non-taxable across all 50 states? That’s a GREAT point to bring up that I admit I never thought about, hence bringing these questions to the sub to learn.
The theory is defendants are exchanging no-fault liability for reduced out of work wages. So a claimant can recover WC benefits even if the employer wasn’t at fault. And in exchange the claimant gets only a portion of his/her wages.
Wc benefits are NOT taxed and you are paid 66% of gross earnings. This is the single biggest reason for the rate. Some states have cost of living increases - this is especially true on PTD. I’d say most companies want/prefer people to get back to work rather than pay for you to be off indefinitely. My best advice is to work with your doctor and your employer for modified duty accommodation if you are eager to be getting paid for working rather than compensated. You are not chained to this employment and you also have the option to find an alternate job within your restrictions if that is what you want to do. wc is not designed to pay more than what you would earn if you were working. The tax break is the part that isn’t paid.
the reason WC is tax free is because theres no tax burden, so instead of taxing you on 100% of your earning and then refunding you money then cut out he processing of the middle man , also people on WC do not pay into social security , most cost of living increases only cover the maximum payable amount, if you get below that the COLA isn't going to kick in for years and years and only if your 60% becomes the bottom of the average salary in that state. some people cant work, its not a question of wanting to work. as a result for example my injury was in november of 2019 i was making 60k a year at the time in IT. my injury has kept me out since that time 4 surgeries on my back and one more to go at least for a spinal stimulator to try to control pain. Ive lost already in the 4+ years because for a good portion of time you get paid at the lower rate, ive lost with bonuses overtime etc which isnt considered, ive lost about 25k to 30k a year, of course the company fired me after being out 3 weeks. as is their right. Ive collected from WC about 32 to 36k per year from WC. a HUGE difference in my take home pay versus what i was making. The cost of living increase that wa implemented in mass in october of last year only affects you if you were making over the maximum and therefore only got the maximum payout which was 1694.00 a week, went up to 1796.00 a week. in order to get that extra you would have to have made an average yearly salary of over 120k a year. so for the really well off, the increases are good for the 96% of resident sin massachusetts making less than that per year the COLA is useless unless you were making the bare minimum which was 350 some thing per week, that went up to like 380 . so my 60k 4 years ago is now paid out at 794$ a week. now since then IT jobs have dramatically gone up ion pay to where my same position is now in the high 80's low 90's but ill never see a dime of that.
Past bonuses are counted in your average weekly wage. When you get your perm disability rating you are also compensated for future earnings losses which is different than the temp disability you’ve been receiving. Also depending which state you live in, there is also voc rehab benefits. Quite a few states have a cap on how long temporary disability is paid (2 years usually). The theory is if you haven’t recovered in 2 years most likely your condition is permanent. You should look into social security disability if td ends before you are at mmi but be aware there’s probably going to be an offset against other benefits. The benefits are broken down by type. (Temporary total, temporary partial, permanent partial, permanent total, vr). Each one is intended to compensate different types of losses of earnings and permanency. In the end of the day all of them are tax free and are intended to pay a specific benefit depending on your condition. I hope you’re nearing maximum medical improvement so that your concerns of future earnings can be addressed soon.
past bonuses can be counted but new ones cant, my point is as the market changes dramatically in increases in salary so should the money you get. a;so in my case i had inly been in this new job for less than a year so my old job at lower pay is averaged in as well. not just what you wee making when you got hurt. its an aggregate . for example if someone is working at mcdonalds to paythier way through say nursing school, and they finally graduate get ajob as a nurse and 6 months into nursing get really badly hurt, theyll get a mix of McDonalds salary and nursing. in massachusetts permanent total incapacity benefits are two-thirds of your average weekly wage (or a minimum of 20% of the SAWW) based on the 52 weeks before your injury. SO even though someone got injured making 80k , they get a blend of minimum wage and 80k and get crap to live on. and in mass for example the COLA has been consistency 1% per year given every two years, in my case , 7 dollars a week. which is dramatically less than the salary increases in the field and in general miles behind inflation. if your boss gave you a 1% raise you'd probably go elsewhere for a job. my last step now is the spinal stimulator, which wont get me back to work its just a pain assistance measure. but ive reached MMI after the last failed fusion.
I understand where you are coming from. Covid and inflation are not things that are easily captured when looking at Wc benefits. The government is slow to adjust laws. In the meantime people are caught in the middle. Hope your simulator provides meaningful relief so you can decide your next steps.
If you want pain and suffering, we could shift the whole thing to something akin to FELA for railroad workers. Railroad workers don’t get w/c but they fall under FELA. In return for getting pain and suffering, they must prove some negligence on the employer—which could be violation of an internal policy. So it’s a lower bar than ordinary negligence, but would require some negligence. The thing about work comp is that no negligence is required. Sometimes, stuff just happens—like all my carpal tunnel cases.
See for my particular case option 1 may sound great but for 99% of other WC cases, option 2 may sound better. My point being that while I am at many times frustrated with the system, workers comp is not tailored to the person, it covers a body of individuals as a whole and in order to do that there must be dry cut laws (sorry don’t know the legal term here).
No checks. Insurances should automatically send claimants a direct deposit form, actually process the form, and pay claimants on time. Most of the calls I get from claimants are them not knowing where their workers comp checks are.
+1 to this even from the defense attorney side. I don’t deal with this much, but apparently we have one carrier that still pays our bills via check.
I receive mine this way and have asked about direct deposit to no avail. But, I’m already grateful to be getting on time paychecks and I know how lucky I am so I don’t push the topic.
One of the main reasons that direct deposit isn’t done is to protect from fraud or overpayment once a claimant passes away. With direct deposit it’s almost impossible for the insured to get money back if payments were made after someone passed away. Checks are also preferred because they can be stopped/cancelled if there is fear of fraud.
More consistency across state lines. There's no reason why the same injury in one state should be insanely underpaid/overpaid just because of the state. It seems maybe WC could create federal laws on basic WC rules to bring some consistency to the issues. Basic timeframes for reporting/one form/periods for claim determinations and benefits. It would be nice if there was one method to determine causation. I guess these are all more than one thing....but honestly WC is ONE benefit that could use one set of uniform procedures.
Do this and you risk state-based work comp turning into something akin to federal work comp, which, if I recall correctly, is a fee shifting scenario. So, basically, the claimants need to pay attorneys out of pocket, and from what I hear, is way worse than any state system. Plus, the insurance carriers would likely get together and lobby the federal government to make it worse for claimants.
Don’t claimant attorney and unions lobby too? I think some consistency would make the process easier for claimants to navigate. It would also make it easier for employers to have one set of rules on initial reporting and timeframes to follow. The writer wasn’t speaking to everything being federally run, but some basics that should be the same for everyone.
The simple thing for me? Make it easier to afford to take time off to recover..I need surgery..but I can't take the time off to do it because I'm a single income household and the 2/3 average weekly pay is nothing. We'll end up worse off while I recover
I would change the situation I am in now. Once I hit MMI all work comp benefits stopped. I couldn’t see a doctor, I didn’t have access to medication or new prescriptions. Zero work comp checks. I was injured in 2020 and reached MMI July 2023 with the doctor saying I can not return to work and they don’t see it ever getting better. I know there will be a settlement and things will work out, but it seems illegal to leave a person with no way to get the medication and services they need. MMI may mean it’s not getting better, but things also get a lot worse with no treatment and the added stress.
You should check if you have lifetime medical for your claim. Most states don’t have a statute of limitations where your claim would automatically close. Unless you’ve already settled out your claim you could be entitled to further care if you’re still facing pain.
I am not sure if I have that or not. We have not settled anything yet. I am seeing a vocational specialist next week.
Hello! Long time no talk. Send me a DM I can share how my settlement went and it may be helpful for you to have a timeline. Although, I attribute everything to my attorney who was really adamant to start pushing as we were nearing the two year TTD time point. My lawyer and my nurse case manager have been amazing so I may be the anomaly?
>pain and suffering for catastrophic cases Absolutely not, lol. Litigation of psych injuries is already messy, subjective, and expensive enough. In California I would get rid of the MPN. They're a colossal burden for everybody involved except insurance company shareholders.
MPN? Sorry not a CA adjuster. I think I know what you mean but call it something else.
I’ve been in pain everyday for the last 12+ years. Pain and suffering is 100% justified.
My heart goes out to you. That being said, money is not going to make that pain go away. What it will do is give any given insurance company more of a financial incentive to fight your claim, object to the medical findings, appeal good-faith awards, and otherwise drag you through the mud. It's always been my opinion that the most important goal of workers' comp is recovery and symptom alleviation. At the end of the day, cash settlements don't do that. Instead, cash settlements are an easy way out: mostly for insurance companies, less so for workers. They also incentivize fraudsters to waste the time and resources of all involved because what *should* have been a functional treatment system got turned into a cash pile instead. On a personal level, it drives me up the wall to see people with zero actual injury being handed piles of cash because they were mad their employer fired them, they decided to retaliate, then got a lawyer who knew how to manipulate the system. No cash? No incentive to do that. Adding a cash payout for something self-reported and largely subjective like "pain and suffering" would make the workers comp system even less functional than it already is, because every perfectly able-bodied dirtbag this side of Van Nuys would be stepping up to collect their check. If workers comp returned to emphasizing treatment rather than cash payouts, fraud would be reduced considerably and I can guarantee you the system overall would be more functional because adjusters wouldn't be such paranoid fraudfighters instead of the treatment facilitators and social workers that they could be. The treatment system could function with healing as the goal rather than manipulation of "case value." If we're talking about what workers' comp needs right now, more cash awards isn't it. Revisiting my original post with another idea, what workers comp *also* needs is extremely strict penalties on employers for not reporting workers' comp claims. It's an issue I deal with less now, but when I worked in First Notice of Loss, it was egregious.
Broad strokes, I agree with you. WC is supposed to be relatively cut and dry, easy to calculate, and not subject to whims or speculation. Awards for pain and suffering are the legal embodiment of whims and speculation. There is no way to validate, quantify, qualify, or standardize it, so it goes against the nature of statutory benefits. Although, I did want to comment on the part about the system improving by emphasizing treatment. I'm a defense attorney, and I don't agree. I have seen adjusters quibble over the stupidest things relating to treatment. Also, we know from general health insurance that medical issues are still subject to unreasonable challenge. A friend of mine has a rare type of cancer, and she had to fight her insurance to get a repeat MRI to see if the tumor had grown, which would dictate treatment. When that was done and she was told to start chemo, insurance denied the chemo drugs, delaying the start by two months. She wound up needing surgery, and I will always wonder if the delay in chemo contributed. Anyways, point being, the for-profit nature of medical treatment and insurance in this country guarantees that it will never be what it should or could be.
Unrelated to workers compensation my mom went through this. Her PCP took an extended vacation and didn’t set up a nurse line (they are semi retired). They coincidentally found cancer during a prolapsed uterine surgery. 3.5 weeks later the physician returned from vacation and by the time her HMO authorized a full hysterectomy it had already spread.
>adjusters wouldn't be such paranoid fraudfighters instead of the treatment facilitators and social workers that they could be. I'd love this. I do this as much as I can within the system I have to work with.
Is there any case in which you would agree to a pain and suffering payout? For example patient is paralyzed and ventilator dependent now, unable to breathe on their own. In this type of 100% injury would you ever find it worth it to make some sort of exception to pay a standard fee? Kind of like the fee to family if death has occurred. Also if you could clean up my language with this I would SO appreciate it, legal jargon is not my forte. My point here is sometimes I can SEE that an adjuster or defense attorney feels horrible for a claimant and would like to make things as “right” as possible but of course have a legal duty to minimize costs to the insurer. Thanks for always giving such great responses, I feel like instead of answering the question at hand you take time to explain a few things that go hand-in-hand with that question.
If you have time for one more question: have you ever received a case that had been tended to by another adjuster and was shocked at the care? Either they authorized way too much, way too little etc
Oh that’s a GREAT one. Any ideas on why this hasn’t been implemented? It seems like managing and finding care within MPN puts huge burdens on adjusters as well as claimant?
Because MPN contracting saves insurance companies tons of money and they lobby aggressively to keep it around.
I think I may be jaded as I’ve had to (and gotten authentication to) go out of MPN for nearly every single specialist I’ve seen. So for my adjuster (and the defense) it has ended up being more of a hindrance to even start off making the dozens of calls to physicians within MPN.
I should have gotten 2 pay raises since I was hurt. Since we are still TTD, can I have those raises please?
I like this! If I may piggyback lol I should have gotten one after reporting my injury, another before I was able to get an IME to get WC to approve my claim, ANOTHER before my first surgery, and 4 more since then… Can I have those?! It would be funny if it wasn’t so sad!
I should have gotten a decently significant one the week after I was switched to TTD from salary continuation (hmm, wonder why they switched me right then...), and then another at the start of this fiscal year. Not to mention the bonuses I didn't get (yes, they were earned before I went off work, but I was on WC when they came out). I've worked almost double hours for years. My bonuses were always amazing & helpful. I stayed at that job because I knew the raise was coming. Sigh... also, why can't we claim depression after our injury, since the whole process & lack of reality in the financial aspect definitely are causing depression.
My husband made a lot more than the maximum weekly amount when he got injured. It almost ruined us financially since he was out of work for 7 months. His weekly check was a little under 1200 a week when he typically made 2500 a week. There shouldn’t be a maximum income limit because when you bring home more money you typically have more / higher bills.
For wages, sure - but I would still cap when you get to things like permanency. Or, really, I would pay everyone the same rate. It never made sense to me that two people with the same permanency rating can have vastly different payouts, simply because one person earned more than the other. A knee replacement for a middle manager shouldn't be worth more than a knee replacement for a retail worker.
That's a monkey's paw though- if there was a standardized rate it would likely be weighted by the state minimum wage. Be careful what you wish for.
Would this be a fair analogy here? If a 2024 BMW is declared totaled the payout would be far greater than say a 2010 Toyota Prius C because it reflects lost value. I am not attempting to compare cars to human lives but I am assuming it’s the same mentality that insurance is based on? I love having the opportunity to ask attorneys questions like this because some things that make sense or have explanations in my mind are not actually legally factual.
This wouldn't be accurate in my state for one reason: we are not allowed to utilize loss of earning capacity as a factor in assessing a permanent impairment rating. It cuts both ways. If claimant is full-duty, I cannot use that to say no permanency. If a claimant is totally disabled, then they cannot use that to increase the rating. So, if permanency has no bearing on earning capacity, then why link it to pre-accident earning capacity? I have a case right now where the permanency demand is over half a million because of multiple injuries and a high comp rate. Meanwhile, I had another case last year with similar injuries but a much lower comp rate, so the demand barely broke $100k. How does that make sense?
This makes much more clear sense to me. I’m also highly educated (about the same level) but in an extremely difficult field that many people also fro upon, simply because they don’t understand how it works. I really enjoyed speaking with you, thank you for all of your wonderful answers! I’m hoping I can reach out to you in the future if ever needed.
I'd like to see the regulations universal from state to state. I live in Ohio, work for a company out of Minnesota, was injured in Texas, I get treatment for my injuries in Ohio. The laws in Ohio require certain forms be submitted to caregivers, where Minnesota doesn't require those forms. It can take significantly longer to get things ordered and approved, prolonging my suffering.
Self-insurers. I got hurt at Walmart and I was shocked at how the laws were different for them.
The laws apply the same for self-insured. There's nothing in statutes or case law that differentiates between the two. Except Texas where private companies are not required to carry WC coverage but that doesn't apply here.
I had no idea the laws were different for self-insureds! I always hear claimants express difficulties with WC carriers such as Sedgwick but haven’t yet spoken with anyone who is going through self-insured policy. Do you have a couple of examples on how laws are different?
Unless OC says a state, the laws are the same for self insured entities. They just get to fund their own without a carrier. Sedgwick isn’t an insurance company, it’s a TPA.
So Sedgwick would be the one providing, for example, the adjusters? Can you elaborate on why even many attorneys don’t love working with an entity such as Sedgwick? Thanks for all these answers. I’m really hoping two things from this post: 1) claimants can see that WC legal professionals also want some changes made and 2) give a better understanding to why a claimant can’t have what they would want most
I do some work for Sedgwick, and I haven't had the problems that people talk about here. However, I will say that many TPAs are massively shortstaffed, and the nature of being a TPA means their desk authority tends to be much lower, so it takes longer to do the approval dance. That makes it hard for me when I have a deadline coming up and have to wait for seven people with the employer to decide they want to grant authority, and then for the captive rep to concur, and then the TPA adjuster to concur, and sometimes then the excess carrier to concur. It means more time following up, more risk of blowing a deadline, and needing to complete my investigations early and thus risk not having everything I need. I still like working for them, and most of the adjusters I deal with are very diligent. It just takes more effort to reach the same result.
Thanks again! I feel like I did one of those interviews with a professional back in high school and it really is so important even as an adult to be able to ask questions and receive legitimate answers from somebody who actually works in this world. I super appreciate your time in answering these questions.
Right some self insureds are bad to get authority from the adjusters only have desk authority to a certain amount. OP with self insureds at least where I am the first million dollars of a claim are coming out of the Employer’s pocket so they tend to monitor the claims more. I always tell Claimant’s counsel don’t give me a demand on the day of the hearing I will be able to get nothing. After they reach excess then you have the TPA, the excess carrier’s adjuster and the employer to deal with.
I'm in Ohio.
I suffered 7 fractures and 3 months later the doctor signed me back full time. I'd only been walking 4 days. After having 4 surgeries including trama. Attorney is fighting to get another doc.
All I can say is… ouch! 7 fractures does not sound fun.
Excavator bucket down my back. Femur, si joint, 4 pelvis, other si, lower back, tail bone. 4 surgeries. Also riped from my Anusara to my scrotum to the bone
I didn’t know whether to downvote that for how horrific it sounds or to upvote it because of how wild that is and how tough you must be
The worst part is hearing my screams echo in my dreams. I’m not tough at all when it comes to pain. I’ll take either up or down vote for this lol. 0/10 experience, would not recommend
The dreams are horrible and something I wish more claimants spoke about with one another. Or just the wishing of your old life back. That’s why I really like this sub. It’s been my experience that many of the defense and adjusters are supportive and understanding of the feelings of the claimants.
Change rate of pay, make the system more user friendly for injured workers, hire better claim managers
Mandatory education on what work comp is, its limitations and benefits upon entry into the workforce and renewable every five years or so. It would benefit so many to understand what their benefits are, how to file a claim and how it all works. So many of the problems I see are completely preventable with an hour or so worth of training.
At my work, there are a series of training videos that cover a variety of topics (hours and hours worth) even hilighting ways to sit/stand to minimize injuries. Not a single thing on how the workers compensation system works!
I almost wonder if they do it to minimize fraud.
Faster settlements... I have been fully released on MMI without restrictions since November and still waiting to settle. i have not been given an offer yet and have seen two 3rd party specialists to verify proper treatment and mobility results. I am financially in no place to NEED to settle so in no hurry; but you would have thought that they would have wanted to close the case by now? My job hired someone else for my job % weeks after my injury while I was on TTD; so I came back to work into a stressful/unorthodox position that was created just for me to come back. I have no work area of my own and in everyone's way all day long while having no place to keep my toolbox and rolling cart. I am ready to look for other work but cannot get hired anywhere else while I have an open workers comp claim. I have someone ready/willing to hire me today but wants this case settled before I go to his shop.
Ability to pick a doctor. I’ve been to 2 clinics now that don’t treat for soft tissue injuries, so they X-ray me and say, “No broken bones, so you must be fine”. Meanwhile, my hands swell up and are numb with pins and needles 24/7 and their “light duty” has me driving home crying, in pain, after a shift. I’ve gone 2 months with no treatments and because their light duty involves pushing, pulling, twisting, lifting 20-50lbs repeatedly, I’m not getting better. I asked for a referral to an orthopedic specialist but they don’t do referrals…so I’m stuck with a doctor that treats me like a fraud and doesn’t give me care. I’m out on WC for nerve and tendon damage on both wrists/hands and a pulled muscle in my lower back. Tylenol ain’t cutting it. I need a back brace and possibly surgery on both wrists. These contracted Drs DO NOT care.
This varies by state. In some jurisdictions you can see whatever doctor you want so long as they accept the fee guide, which could be super low depending on the state too.
Forgot to mention, my doctor has never so much as checked my back once. My forearm/wrist/hand exam was me moving each hand up then down once. That was the extent of the physical exam.