Not so fast. The rules that apply to workers compensation can be confusing, arbitrary and harsh. The rules are listed in Georgia Code Title 34, Chapter 9 and the rules and regulations published by the State Board of workers compensation. A small mistake can end up cost you thousands of dollars in lost benefits.
Workers’ compensation is full of rules that can damage your case if you are not aware of them. There are rules about notifying your employer when you get injured, who is in charge of selecting the treating doctor, when and how you're able to change doctors, how long you can draw weekly check, when you can get a hearing in front of a worker's compensation judge, etc. There is a big difference between being entitled to workers' compensation benefits and actually receiving them.
Workers Comp is meant to compensate workers who have on-the-job-injuries.
From the first day of your injury, the workers compensation insurance carrier is looking for a way to reduce the amount of benefits that they will pay. When you have a workplace injury, none of your workers compensation benefits are guaranteed. Your rights to benefits depend following a very specific set of rules and laws. The insurance adjuster is an expert at using the rules to cut off your benefits as soon as possible.
The insurance company might have initially accepted your case, but that does not mean they are not actively working on a strategy to end your benefits as soon as possible. The insurance company is a business, and their only goal is to reduce the amount of benefits that they will pay you. Workers' compensation is a lot like a game of chess. When you make a workers' compensation claim, you are making a claim for insurance benefits that could potentially cost the insurance company hundreds of thousands of dollars or more. The stakes are high. You are potentially entitled to receive lost wage benefits, medical benefits, and money for permanent impairment.
If benefits have been denied to you, you have a right to request a hearing. But this is not a civil court hearing and your claim for workers compensation benefits is not public record. All hearings for workers compensation benefits take place before the Georgia State Board of Workers' Compensation. There is no jury in a workers compensation case. If you need to file a hearing to request benefits, your case will be decided by an administrative law judge.
The first step is carefully selecting the doctor who will treat your injury. You have a right to choose your treating doctor from a list of doctors called a "panel of physicians." Every employer is supposed to have a list of doctors available to you. Your rights to workers' comp benefits are mostly controlled by the doctor you select to treat your injury. The law gives this doctor a tremendous amount of power over your rights to benefits. One common way insurance companies can hurt your case is by trying to force you to see one of their favorite doctors. It is very common for the insurance company to contact the doctor behind your back, and try to get them to say you were not really hurt at work, that you are ready to go back to work without restrictions, that you don’t deserve any money for permanent impairment, etc.
There are some Medical Providers who focus on workers' compensation insurance and get hundreds of patients directly referred to them from the workers compensation insurance companies. One of the biggest mistakes we see is going to an "industrial clinic." These companies know they will get sent more injured workers if they help the insurance company instead of you. Some examples of industrial clinics are:
This is not a compelete list and you need to be very careful about who you choose to treat your injury. Did the insurance company tell you that you "have to" go to the industrial clinic? This is very common and it is also a straight-up lie. The panel of physicians will often (but not always) label these providers as an "industrial clinic." Clinics will often refuse to put you on a "no work" status, even if you have a serious injury. If you search their website, you may even find them bragging in their marketing materials about how much money they save the insurance company by not taking injured workers out of work. We have even seen clinics that drug test every injured worker, and it doesnt even matter how you got hurt. If a drug test show a positive for a substance like marijuana, they will forward the results to the insurance company so that they can try to deny your claim.
Selecting the right doctor from the panel of physicians is not always easy. Check out our workers comp medical benefits guide for more information.
After you notify your employer of the accident, they are required to report the injury to their insurance company. The insurance company will investigate the claim. The insurance company can either accept your claim, accept your claim as "medical only", or deny your claim entirely.
In an accepeted case, the insurance company will start paying your benefits voluntarily without the need for a hearing. Workers' compensation often works very well for people who have short term injuries requiring only a few doctor visits. For example, if need stitches and do not miss any time from work, then you likely won’t have many problems with workers compensation. But if you have a medical problem that will last months or years, you have just entered a fierce competition with the insurance company.
In a "medical only" case, the insurance company has accepted that you suffered an injury, but is not paying you for any lost time from work. If your case has been accepted, your main goal should be to make sure that you are reciving timely medical care and that your benefits do not end prematurely. You may wat to check out our "lost income benefits" section to learn about how the insurance company can cut off your weekly check.
In a denied or "controverted" case, the employer is denying that you had a compensable workplace injury. Workers compensataion law is complicated and the reasonas an insurance company can deny a claim are numerous. TEchnically, the insurance company has up to 81 days to deny your entire case. They can still deny your case after 81 days if they never paid you a weekly check or basedon on "newly dicovered evidence." Some common reasons are: they say you are lying about the accident, that you failed to disclose a pre-existing condition, or that your accident was the result of intoxication.
When the insurance company decides to deny your whole case, they are supposed to send you what is known as a WC-3 "notice to controvert." At this point, you have very little choice but to request a hearing in front of the State Board of Workers' Compensation. You will want to speak with an attorney to get this process started. Check out our workers comp guide to denied benefits.
Report the injury. If you are injured in the workplace, you must report the injury to your employer. Some employees are fear retaliation from the employer if they report the injury. However, waiting can be a big mistake. If you wait more than 30 days to report, you may have your case denied for late reporting.
If you have 7 days or more of lost time, make sure workers comp pays you the correct amount of lost income benefits. To calculate the amount of your weekly check, Workers’ comp uses the 13 weeks of income from immediately prior to your date of accident. Your check will be for two thirds of your average pay. Workers’ comp will often mess this average up. For example, they will “forget” to include your overtime pay. You should always double check the amount they pay you.
Ask to see the panel of Physicians. This is the most important thing you can do after a workplace accident. Don’t let the insurance company pick the doctor. You should get a free consultation with an attorney before you select the doctor.
Unfortunetly, unwarranted delays in medical treatment are very common in Georgia. If the treating doctor reccomends an expensive treatment, workers' comp often does not want to pay. They may simply ignore your doctor's request to authorize the treatment. Most doctors will not treat you until they recieve "authorization" from the insurance company. The doctor does not want to get stuck with a bill that the insuance company will not pay.
Insurance companies will often deny and delay care if you don't have a lawyer. The reason is that it saves them money. They know that there is not a lot an unrepresented worker can do, so they just ignore you. If you have a lawyer, they are more likely to quickly approve your treatment. An attorney will file for a hearing and request penalties if they unreasonably deny or delay your treatment.
If the insurance company is ignoring your doctor's request to authorize treatment, we can file a Form WC-PMT (Petition For Medical Treatment) with the state Board of Workers Compensation. When this form is properly filed, it forces the insurance company to give an answer to about whether they will authorize your treatment. If the insurance company does not give an answer, then a teleconference with a workers compensation judge will be scheduled. This is an expediated process and only takes about a week.
If the insurance company formally denies or "controverts" the reccomended treatment, your only option is to request a hearing in front of the Georgia State Board of Workers' Compensaiton.
You have not preserved your right to workers compensation until you file a WC-14 "notice of claim". You need to complete and file a WC-14, with the State Board of Workers' Compensation and send a copy of the form to your employer and their workers' compensation insurance carrier. The State Board of Workers' Compensation will provide you with Form WC-14 to file a claim or you can get a copy of the WC-14 from the Board's website.
If you never filed a wc-14, then the clock is ticking in your workers compensation case. You must file a claim within one year of the date of the last authorized medical treatment or two years of your last payment of weekly benefits. If you let these deadlines pass, then you will forfeit your right to workers compensation.
If you are totally disabled and unable to return to work, you are limited to 400 weeks (6.5 years) of benefits, unless your case can be designated catastrophic.