Q.    How does the worker’s compensation system work? 

A.  When the worker’s compensation system is operating properly, a worker who is injured on the job goes to the doctor of his or her choice in Wisconsin for treatment.  If the doctor places the worker  on full restrictions from work, the worker collects temporary total disability (TTD).  This is 2/3’s of the worker’s wages (although the amount is subject to certain caps).  If the doctor places the worker on partial restrictions and the employer cannot or will not accommodate the restrictions, the worker still collects TTD.  If the worker is able to go back to work part-time under a doctor’s restrictions, he collects temporary partial disability (TPD).  The worker is entitled to TTD or TPD during the entire time period that the worker is unable to work and in a healing period, according to his or her doctor. Once the worker reaches the end of the healing period, also known as maximum medical improvement (MMI), the doctor may assign a permanent partial disability (PPD) rating.  This is expressed in terms of a percentage of disability to the body part that is injured.  This PPD rating is then converted to a monetary amount and awarded to the worker.  Sometimes, the doctor assesses permanent restrictions in addition to the PPD rating.  If the employer cannot accommodate these permanent restrictions, additional benefits may be available. 

Q.      What benefits am I entitled to in worker’s compensation? 

A.      If you are injured on the job, you are entitled to payment of all medical expenses (no deductible), mileage for all medical treatment, TTD or TPD during the period of time that you are off work, and PPD if your doctor provides you with a PPD rating when you reach your end of healing.  You are also entitled to return to your job if your permanent restrictions do not prevent you from performing the work.  If permanent restrictions do prevent you from returning to your job, you may be entitled to retraining benefits or additional payments for loss of earning capacity caused by your restrictions, depending on the facts of your particular case. 

Q.      Do I need an attorney? 

A.      The rule of thumb for when you need an attorney is relatively simple.  If your employer or your insurance company are not listening to or complying with your doctor’s orders, you need an attorney. At any point in the process if you have questions, call an attorney.  Worker’s compensation cases are handled on a contingency basis, based solely on recovery of benefits that are disputed.  In other words, calling an attorney and getting advice should not cost you anything.  If an attorney wants to charge you for a consultation or a review of your worker’s compensation case, find another attorney. If you have a clear work-related injury, and the insurance company is paying for your medical bills, your mileage and providing TTD benefits while you are off work, you probably don’t need an attorney.  The insurance company is required to report their payments and their activity to the Department of Workforce Development (DWD) and the benefits are based on established statutory formulas. 

Q.      What is an IME? 

A.      During the course of your medical treatment, the insurance company may send you a letter advising you that they have set up a medical exam with a doctor for what they often call an “Independent Medical Examination” (IME).  In actuality, there is not much that is independent about this examination.  The insurance company wants you to be seen by a defense doctor.  They have the right to do that.  You must comply.  Unfortunately, this is often the first step for the insurance company to deny your claim.  There is something about your case that is causing the adjustor for the insurance company to question what your doctor is saying about your injury being work related, or the extent of your treatment or disability.  In order for the insurance company to deny the claim, they must have their own medical support to claim that your injury is not work related or that your injury is not as extensive as your doctor is claiming.  As a result, they have you seen by their own doctor.   You must attend the IME and cooperate with the examination.  However, once you get the letter notifying you that an IME has been scheduled, it is probably a good idea to consult with an attorney. 

Q.      My doctor has given me a return to work slip with restrictions, but my employer is making me work beyond those restrictions.  What should I do? 

A.      Call your doctor’s office and let them know in detail what your employer is requiring you to do, and confirm that this is beyond your restrictions.  Make sure the doctor's office makes note of the call and the confirmation that this is beyond your restrictions.  Sometimes the doctor or someone from his/her office will contact the employer directly.  Regardless, it is probably a good idea at this point to call an attorney. 

Q.      The insurance company has assigned a case manager (usually a nurse) to monitor my care.  Is this allowed? 

A.      This is allowed.  Often, a case manager is assigned to a claim if the injury is serious.  Ideally, the case manager is there to help communicate between the employer, the insurance company and the doctor.  Different attorneys take different approaches regarding nurse case managers.  In my area of the state, many case managers are dedicated nurses who sincerely try to ensure that the employer understands the worker’s compensation system and their obligations to the employee under that system.  They also try to make sure that employers accommodate the doctor’s restrictions and try to get the worker back on the job as soon as possible.  This is a valid goal under the worker’s compensation system.  It is always better for you if you can get back to work as soon as possible, if your doctor feels you can work. As noted above, in my experience, many hands-on nurse case managers are very professional in this area of the state, but you must remember that they are hired by the insurance company.  If you feel the case manager is advocating too hard in an attempt to limit the care from your doctor, or if you feel that the case manager is not accurately communicating the information between the doctor and your employer, you should consult with an attorney. 

Q.      The worker’s compensation insurance company began by honoring my claim, paying my bills and providing me with benefits.  After the IME, I got a letter telling me that the claim was being denied based on the IME report.  In addition, the claim was being denied retroactively.  The letter advises that all their payments were paid based on a "mistake in fact," I have a right to apply for a hearing if I dispute their conclusion, but if I do, then they will or might claim reimbursement for all benefits paid to date.  What should I do? 

A.      As noted above, the moment the insurance company or your employer does not agree with or follow your doctor’s opinions and advice, you need an attorney.  One thing to understand, I have been involved in Worker's Compensation cases for over 25 years.  While there is language in the statute that allows an insurance company to claim reimbursement for payments made based on a mistake in fact, I have personally never seen an order granting the insurance company reimbursement.  There are things that you should do on your own once your claim is denied.  Make sure that all of your medical care providers are aware of your personal health insurance information and plan, and that they forward your bills to the health insurance carrier.  Make sure your doctor is part of the preferred providers in your Health Insurance Plan.  Sometimes, the health insurance company will initially deny payment of the bills because they exclude work-related injuries and you are already on record as saying that this was a work-related injury.    Usually, if you send the health insurance company a copy of the denial letter from the worker’s compensation insurance company, the health insurance company will begin paying the medical bills.   Unfortunately, those bills will be subject to any deductibles and co-pay obligations.  It is probably a good idea to consult with an attorney at this point.
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