Benefits available after claim acceptance
1. Lost Wages
In order to receive lost wages, you MUST have written work restrictions from your “attending physician”. The doctor can make the restrictions open-ended or for a specific period but they can only backdate restrictions for 14 days so it is important to keep them current.
Lost wages are to be paid every 14 days and are based on 2/3 of your average weekly wage with the employer at injury. The average goes back to 1 year prior to the injury. If there were seasonal or temporary lay-offs, the average should start after the return to regular work.
Wages from a second job can be factored in. If you had a second job, you should notify the insurer as soon as possible. They will need verification that you were still working the second job at the time of injury and copies of your wage records.
It is up to the employer whether they want to provide modified work within your doctor’s restrictions. If you return to work with reduced wages, you may be eligible for partial disability payments to make up part of the difference.
Keep in mind that the insurer is only required to pay wage loss when it is due to an accepted condition. They are not required to continue payments if the claim is denied. If the denial is later overturned, the insurer usually has to pay the lost wages back to the date of the denial.
If payments are delayed or improperly withheld, the worker may be entitled to a 25% penalty on the total amount.
If lost wages are being denied, you may want to file for unemployment benefits. In order to qualify, you must be able to perform some type of work and willing to look for work within your restrictions. If you are later found eligible for workers’ compensation payments, you must notify unemployment and workers’ compensation so you do not receive double benefits. You should also contact an attorney to discuss this.
2. Medical Services
The insurer must provide reasonable and necessary medical services to treat the accepted condition and services necessary to diagnose the condition. They must also reimburse the worker for prescriptions.
If you are unable to pay for your prescriptions or the insurer denies them you should contact an attorney as soon as possible.
Your attending physician is responsible for making referrals and justifying the treatment he or she recommends if it is challenged by the insurer.
All medical providers are required to submit their bills and chart notes to the workers’ compensation insurer. If they have questions they can feel free to contact us.
Even if the claim or service is denied, we strongly recommend the doctors bill workers’ compensation first and other health insurance second.
It is very important to obtain a complete diagnosis and treatment as soon as possible (even if you have to use other health insurance). If the comp insurer starts denying benefits, it is helpful to have a specialist involved. If surgery is required, it is often helpful to have that surgery performed early on so that the specialist is in a better position to comment on the cause of the condition.
If the insurer denies medical services we can appeal their decision but many doctors will not proceed with treatment until they know that insurance will cover the costs.
3. Permanent partial disability
The insurer is required to compensate you for “ratable impairment” caused by the conditions they have accepted. This includes compensation for your inability to return to your normal work.
Once you reach maximum improvement, your doctor should perform a closing exam or refer you to someone they trust for those purposes.
After your doctor agrees with the impairment findings, the insurer will translate the impairment findings to a dollar amount using the rating criteria and formula provided by law.
Once this is done, they will issue a notice of closure outlining their calculations and the compensation you are entitled to. Time loss will stop after the notice of closure is issued, even if you remain unemployed. However, after 30 days the insurer is required to make monthly payments on the permanent impairment compensation.
The insurer can appeal your doctor’s findings and request a second opinion within 7 days. We can appeal the insurer’s calculations and/or request our own second opinion within 60 days.
The second opinion doctor is chosen by the State at random.
Unfortunately, we are not allowed to have a hearing or give live testimony in this process. Once the State makes their initial decision on review, we can appeal again but we cannot submit additional information into evidence.
4. Retraining/Vocational Services
Once you reach maximum improvement, the insurer will be required to evaluate whether you can return to employment that would pay at least 80% of your wage at the time of injury.
If you are unable to do this as a result of your accepted condition, you may be eligible for retraining or other vocational services. This includes compensation for lost wages while the program is in session.
In some situations, you can negotiate a settlement for the value of your future monetary (non-medical) benefits including retraining. This should be discussed with an attorney.
5. Permanent total disability
If the injury causes an inability to return to gainful and suitable employment, the insurer may be required to pay ongoing compensation at the normal time loss rate.
6. Death and Survivors Benefits
If the injury results in death, the insurer is required to pay transportation and burial costs. They are also required to pay ongoing monthly benefits to a surviving spouse until remarriage and to a surviving dependant until they reach 18 years of age or 23 years if they continue in school.
Links:
Workers’ Compensation Board
Workers’ Compensation Division
OR-OSHA
Bureau of Labor and Industries
Social Security Administration
Oregon Revised Statutes Ch. 656
Oregon Administrative Regulations Ch 436
Oregon Administrative Regulations Ch 438
