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Introduction to Utah Workers Compensation Claims Workers compensation covers injuries & diseases caused by employment. In most cases benefits are paid by the employers workers compensation insurance company without legal proceedings. However, if the insurance company refuses to pay benefits, the Labor Commission is the Court with the authority to rule on the issues. Filing a workers compensation claim with the Labor Commission is filing a lawsuit against the employer and their insurance carrier. Although the Labor Commission is designed to deal with these cases faster than other Courts, a lawsuit takes time. At Atkin & Associates, we understand how injured workers are affected physically, emotionally and financially by the denial of benefits. We always work hard to proceed through the system as quickly as possible. While proceeding through the legal system, we encourage our clients to do everything possible to get proper medical treatment and manage their finances. When benefits are denied, you can receive medical care through your regular health care insurance, or apply for medical assistance such as Medicaid. You can also apply for appropriate financial assistance such as long term disability, sick leave, unemployment, welfare or Social Security Disability. These benefits can then be repaid when the workers compensation benefits are orderred. Benefits Workers compensation benefits are limited by law. This limitation is why Atkin & Associates believes it is important to recover all appropriate benefits possible. Benefits allowed are: Medical Expenses: All medical expenses related to the injury are to be paid. This benefit continues for life provided the workers compensation insurance company is billed for medical care at least every three years. Mileage: 34.5 cents a mile to and from medical treatment. Temporary Total Disability: Payment for time off work when a doctor's restrictions prevent work. Paid until Maximum Medical Improvement (MMI). Temporary Partial Disability: Compensation for reduced wages during light duty. Paid until MMI is reached. Permanent Partial Disability: Impairment ratings are compensation for the permanent injury caused by the industrial injury. Permanent Total Disability: If the injury is permanent and prevents return to work, PTD provides retraining and, may pay benefits for life. Death Benefits: If an injury results in death, burial benefits as well as benefits for dependants are paid. Interest: 8% per annum interest accumulates on unpaid benefits. Filing a Claim Preparation is required before filing a workers compensation claim. Your attorney will fully evaluate the legal issues involved in the claim and request the basic evidence needed to win on those issues. For example, if the dispute involves a question of wages, check stubs or payroll records will be needed. In most cases, the evidence needed is a medical report outlining that the medical condition was caused by work. Four forms are required by the Labor Commission to file a claim: The Application for Hearing outlines the claim for the court. The Appointment of Counsel Form allows the attorney to represent the injured worker. The Medical Authorization allows the release of medical records the court requires. The Health Care Provider List lists all medical providers so that the medical records provided to the court are complete. The attorney files these forms with the Labor Commission and provides a copy to you. Approximately 10 days after filing, the Labor Commission sends copies of the forms to the employer and insurance carrier in an Order For Answer. The Answer 30 days after the Labor Commission mails the Order for Answer, the employer or insurance company must file an Answer. The Answer is required to contain the reason benefits were denied and include the insurance company’s evidence supporting their denial. Unfortunately, Answers rarely contain all the information they should. Often, discovery is required to fully understand the aspects of the case. However, Answers must contain a basic outline of the defenses and the reasons for the defenses. If they do not contain at least basic information, the attorney will ask the Judge to require the insurance company to rewrite the Answer. Once an Answer is filed, the Labor Commission places the case in line for a hearing date. The time before the hearing is used for discovery to fully prepare the case. Discovery There are three basic types of discovery allowed in workers compensation law: Interrogatories, Depositions and Insurance Medical Exams. Interrogatories are written questions to be answered under oath. These are often used to help the attorney for the insurance company understand your accident and history. The attorneys at Atkin & Associates also use interrogatories to make sure they fully understand the insurance company’s legal position. A deposition allows for oral questions and answers. Both the injured worker and the attorney attend. A court reporter is present at all depositions to write down exactly what is said. All answers are sworn to be the truth. An insurance medical exam (IME) is a medical opinion for the insurance company. They have a right to get one and the injured worker is required to cooperate. It is important to be fully honest with the IME doctor. Injured workers are not required to lay in bed and never move. However, if they lie about their activities, they can be accused of criminal fraud. Fraud Accepting workers compensation benefits inappropriately is criminal fraud. The most obvious example of fraud would be to tell the workers compensation insurance company you are unable to work so that you can collect benefits while working and being paid “under the table.” However, fraud also exists where someone lies in order to receive benefits. While Atkin & Associates believes people who commit fraud should be charged with the crime, workers compensation insurance companies have learned to use the criminal system to scare workers out of their benefits. It is common in a workers compensation case for the insurance company to hire a private investigator to video tape the injured worker for a few days. The video alone cannot result in a fraud charge. However, fraud charges may be filed if the injured worker lies and states that he cannot do some activity they have video of him doing. It is vital that you always tell the whole truth about every aspect of your claim. Pre-Hearing Disclosures 45 days prior to the scheduled hearing at the Labor Commission, both sides will prepare pre-hearing disclosures for the Judge. This written document outlines the basic facts of the case and the issues or disputes the Judge will need to address. This includes the calculations for the benefits claimed, including items such as wage rate, benefit rates, and the precise dates off work. This document is designed to make sure all sides are fully aware of the issues and evidence that will be used at the hearing. If either side tries to hide evidence, the Judge will prevent them from using that evidence at the hearing. At Atkin & Associates we carefully prepare our pre-hearing disclosures to make sure all issues and evidence is fully outlined. We may ask you to send certain information or items to assist us in the completion of the pre-hearing disclosures. It is vital that the items requested by your attorney are provided in time for them to be included in the pre-hearing disclosures. A copy of the pre-hearing disclosures will be mailed to you for your records. Medical Exhibit A Medical Exhibit is prepared by the insurance company for the Judge. The exhibit includes a full set of your medical records. 20 working days prior to the hearing, your attorney will send all medical records we have to be included in the Medical Exhibit to the attorney for the insurance company. 10 working days prior to the hearing, the insurance company will send the completed Medical Exhibit to the Judge with a copy to Atkin & Associates. This allows your attorney time to read all medical records. With few exceptions, the Judge will not allow new medical records into the Medical Exhibit after it is complete. Therefore, if your doctor has ben asked to submit a report for your hearing, that report must be done in time for it to be mailed to the insurance company 20 days prior to the hearing. Settlement Options Although not an option in all cases, an attempt to settle the case for a reasonable amount is recommended in most situations. Usually, the injured worker and his attorney decide on a fair settlement amount and make the first offer of settlement to the insurance company. The insurance company can accept the offer, decline the offer or make a counter-offer with different terms. If there is a counter offer, the injured worker can accept it, decline it, or make another counter-offer. This negotiation continues until a final offer is accepted or declined. Settlement can be done between the two attorneys in the case or by formal mediation at the Labor Commission. Mediation The Labor Commission has established a mediation department to assist the parties in a workers compensation case reach settlement. Mediation is simply a chance for both sides to sit down with a neutral person to discuss fair settlement options. Nothing said in a mediation (except fraudulent misrepresentations) can be used against any party. There are three steps in Mediation. First, the parties meet and each attorney provides a basic outline of their side of the case. The injured worker simply listens to both sides. Second, the insurance company attorney is moved to a separate room. This allows each side to speak confidentially with the mediator and discuss settlement proposals. The mediator takes settlement offers back and forth, discussing strengths and weaknesses in the cases. Third, once settlement has been reached or the parties decide settlement is not possible at that time, the parties meet again to decide how best to proceed. If settlement is reached, the mediator will notify the Judge that the hearing can be cancelled. If settlement is not reached, the hearing proceeds as scheduled. Hearing A hearing is an informal trial at the Labor Commission. A Judge will be present to hear the evidence. We want the Judge to know you respect the court, so wear appropriate clothing. For the same reason it is vital that you allow the other side to present their evidence. It is rude and disrespectful to the court to roll your eyes, gasp or shout “that is a lie” when the other side says things you believe are wrong. Your attorney will present the evidence on your side so that the Judge will make the correct decision in the end. At the beginning of the hearing the Judge will address any preliminary issues with the attorneys. This will include admission of the Medical Exhibit and other formalities. The attorneys will then present opening arguments to outline the issues and disputes for the Judge. Then testimony is presented. Hearing Testimony The injured worker is almost always the first witness to present testimony. The Judge will administer an oath where you swear to tell the whole truth. You will then take the witness chair and answer questions from your attorney first. The insurance company’s attorney can then ask questions. Do not try to guess why the question is being asked. Simply answer the question as honestly as you can. This means that sometimes the only true answer is “I don’t remember.” Your attorney will then ask any questions needed to clarify any confusion caused by the insurance company questions. Your witnesses (if any) will then testify in the same manner. In most cases no witnesses other than the injured worker are needed to prove the case because the injured worker knows everything that happened in the case. If the insurance company has any witnesses, they will testify. Questions for insurance witnesses are asked first by the insurance company attorney and then by your attorney. If any of the testimony of the witnesses is incorrect or misleading, your attorney may ask you to testify a second time to clarify the issue for the Judge. Closing Arguments At the end of the hearing, both attorneys present closing arguments. The Judge may ask that this be done orally at the end of the hearing, or in writing shortly thereafter. Closing arguments summarize the case and outline the legal arguments for the Judge. Since the injured worker has the burden to prove his case, each fact presented that proves the case will be reviewed in the closing srguments. The Judge will not make a decision at the hearing. He will "close the record" which means that no new evidence can be submitted. The Judge will then issue a written decision which is called the Findings of Fact, Conclusions of Law and Order. If the case involves a dispute between doctors on a medical issue, the Judge will issue a Tentative Order which outlines the facts of the case and sends the matter to a Medical Panel. Medical Panel A Medical Panel is a panel of neutral doctors appointed by the Judge. These doctors do not work for either the insurance company or for the injured worker. They only work for the Court. Once the Judge sends a letter to the Medical Panel Chairmen with your case information, the Medical Panel Chairman will call you directly to schedule an appointment. By the time the Chairman calls you, he has already arranged the schedules of the other doctors on the Panel. Therefore, please accept the date the Chairman presents. If you have a conflict, move your other appointments so you can attend the Medical Panel examination. The Medical Panel will read the entire Medical Record and review the Findings of Fact written by the Judge. They will meet with you for an examination. The Medical Panel will not tell you their decision. They will submit a Medical Panel Report in writing to the Judge. The Judge will send a copy of the Report to you and your attorney. Any objections must be filed within 15 days. Medical Panel Objections Because a Medical Panel is only requested when there is a medical dispute between your doctor and the insurance company doctor, one side or the other will always think the Medical Panel Report is wrong. We cannot object to the Report just because it disagrees with your doctor. But, neither can the insurance company. If the Medical Panel failed to follow the facts outlined by the Judge in the Findings of Facts, or if the Medical Panel reaches legal conclusions they were not supposed to make, an objection can be filed. Although objections are often filed, legitimate objections are rare. At Atkin & Associates, we will not file frivolous objections and will strongly fight any such objections filed by the insurance company. Once the 15 days for objections has past, the file is ready for an Order from the Court. Order of the Court There are no time requirements for Judges to write their Orders. A Judge’s backlog of cases is outside our control. Complaining about delay only angers a Judge - not something you want to do while waiting for them to decide your case. In 2004 the average waiting period between the time the file was ready for Order and the time an Order was mailed was 6 months. The Findings of Fact, Conclusions of Law and Order outline the facts presented to the Court and the statutes and case law that affect the case. The Judge then discusses how he reached his conclusions. Finally, the Order outlines the decision of the Judge and the payments required. All payments outlined in an Order must be paid within 30 days unless an Appeal is filed. Appeals can be filed by either side, but they are rare. Once the Order becomes final and the payments are made, the case is concluded. Hopefully, at that point, life returns to normal. However, the Judge cannot always predict what benefits will be needed in the future. It is possible for additional claims with the Labor Commission to be needed to resolve new disputes. 
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