An experienced workers’ compensation lawyer can help injured workers resolve cases involving permanent disabilities or disputed facts

Not every worker’s compensation case requires the intervention of a lawyer. When workers’ compensation insurance companies provide adequate medical care for an injury and do not contest the injured worker’s right to receive temporary disability benefits while healing, an injured worker who recovers fully and returns to work will likely receive all the benefits to which he is entitled. A lawyer can give advice if the injured worker is uncertain about procedures, but when injuries are minor, an injured worker can usually manage the claim without a lawyer’s help.

Injured workers are most likely to need a lawyer when:

• The workers’ compensation insurance company contends that no injury occurred and denies the claim
• The workers’ compensation insurance company contends that the injury is unrelated to work and denies the claim
• The injured worker is likely to suffer permanent disability

In each of those situations, a lawyer’s knowledge and experience with workers’ compensation law and procedures will be important to achieving a successful outcome.

Disputes About Legitimacy of Injuries

Lobbyists for businesses and insurance companies have falsely claimed for years that there is a high incidence of fraud in workers’ comp claims. While fraudulent claims do sometimes happen, the insurance industry has vastly overstated their numbers and their impact on the workers’ compensation system.

Emboldened by their success in persuading the legislature and some members of the public that fraud is an epidemic in the workers’ compensation system, insurance companies try to increase their profits by routinely claiming that employees are committing fraud, or otherwise exaggerating the injuries they report to their employers.

When an employer or its insurance company accuses an employee of fraudulent behavior, an injured workers’ lawyer can investigate the facts and develop evidence to prove that there is no fraudulent behavior. While insurance companies sometimes deny claims because they are not supported by “objective” medical evidence, many injuries can only be diagnosed by an injured worker’s subjective complaints. For instance, torn muscles do not show up on X-rays, and they do not always appear on MRI scans. Experienced lawyers know how to present evidence that injuries are real, even if symptoms of the injuries are subjective.

Disputes About Causes of Injuries

Workers’ compensation claims administrators sometimes agree that an injury occurred but deny that the injury is work-related. They might argue that a back injury was caused by heavy lifting at home or that the injured worker was on her lunch break and not performing any job duties when she was injured.

Questions of causation of injury can be complicated because injuries sometimes have more than one cause. For example, a muscle might have been damaged by playing a sport but the damage might be aggravated by working. In those cases, a disability resulting from the injury must be apportioned between work activity and nonwork activity.

Doctors often disagree about apportionment. In some cases, it is necessary to review the injured worker’s medical records over the course of some years to rule out other potential causes of an injury. In other cases, it is important to obtain an independent medical opinion about causation and apportionment.

In addition to medical evidence, an injured worker may need to rely on witnesses to establish where and when an injury occurred. Experienced workers’ compensation lawyers are able to identify and present the best evidence in support of a claim when the insurer disputes the cause of the injury.

Workers’ Comp Disputes About Permanent Disabilities

The most common dispute in a workers’ compensation case is the extent of an injured worker’s permanent disability. Claims administrators have an incentive to save money for the insurance companies that employ them. They will therefore argue in favor of the lowest disability rating that they think they can justify.

The disability rating is determined by using a formula that takes a number of factors into consideration, including the “whole person impairment” (WPI) rating in the report of a Qualified Medical Examiner (QME). Different QME physicians can arrive at very different WPI ratings based on the same medical evidence. Choosing a QME from the list offered by the Workers’ Compensation Appeals Board’s Medical Unit can make a difference to the final outcome of a case. A workers’ compensation lawyer who is familiar with physicians on the list will be in the best position to make a wise choice.

Permanent mental health or psychiatric injuries can be even more challenging to evaluate than physical injuries. Not all mental health injuries are compensable, and insurers tend to treat them all as unworthy of compensation. A lawyer who understands the law and who has a working knowledge of the diagnostic criteria for mental health disorders can make a critical difference in the final outcome of the case.

Other considerations can also have an impact on the final disability rating. A thorough understanding of the complex statutes, regulations, policy statements, court decisions, and agency decisions governing worker’s compensation is necessary to maximize the award of benefits in complicated cases. Only an experienced workers’ compensation lawyer is likely to have that depth of knowledge.

Settlement of Permanent Disability Claims

Finally, even when there isn’t a significant dispute about the facts, there is an art to settling worker’s compensation claims. In some cases, it can be beneficial to negotiate a lump sum settlement. That is when an injured worker gives up the right to have the workers’ compensation insurance company provide future treatment for their disability. The other option is to require the carrier to continue to be responsible for the medical care related to the injury forever. Therefore, injured workers need to be careful and choose the settlement that best meets their needs.

When injured workers don’t expect to need future medical care for the injury or have other insurance that will cover it, a workers’ compensation lawyer can often negotiate a larger workers compensation settlement in exchange for relieving the employer of the legal obligation to pay those future treatment costs. Injured workers generally have no experience negotiating workers’ compensation settlements, and so can rarely predict the “best deal” a claims administrator is likely to make.

Injured workers with permanent disabilities can usually improve their bargaining position by hiring an experienced and respected workers’ compensation lawyer. To learn how a Santa Rosa workers’ comp attorney can help you, contact Kneisler & Schondel at (707) 542-5132. You can also ask us a question by submitting our online contact form.