As a former claims adjuster who worked for a national insurance company, I learned at an early stage in my career as a Colorado injury attorney that the insurance company that insures an injured worker for a workers compensation injury or a personal injury arising from an auto accident or a slip and fall accident does not have the best interests of the injured person at heart. In fact, insurance companies have boards of directors whose sole purpose is to make money for the insurance company. In order to do this, it is the claims adjuster’s or claims representative’s duty to see that your workers compensation claim or personal injury claim is denied and that you receive the least benefits or money possible.
The Colorado Workers Compensation Act’s stated intent is to allow injured workers to represent themselves without an attorney or lawyer. In Colorado, claimants often represent themselves without a lawyer. The reality is the Colorado workers compensation system is very a rule-oriented process and a trap for a Colorado injured worker or victim who is not a Colorado attorney or Colorado lawyer. These are the fifteen (15) secrets that a Colorado claims adjuster or Colorado claims representative does not want you to know, and you won’t, if you do not hire a Colorado workers compensation attorney, a Colorado workers compensation lawyer, a Colorado personal injury attorney or a Colorado personal injury lawyer:
1. In the event you are injured in the course and scope of your employment in Colorado, you have four (4) days to provide written notice to your employer of your work-related injury.
2. The Colorado employer/insurer has twenty (20) days after the filing of the report of your workers compensation incident with the Colorado Division of Workers’ Compensation (the Division) to admit that your injury occurred at work or contest (deny) that your injury occurred at work.
3. If you are injured in the course and scope of your employment in Colorado, you have a right to compensation for mileage to and from your health care appointments. Often times, claims adjusters working for the insurance company “forget” to advise you of this. It this omission is done on a mass basis, this results in millions of dollars of additional profits for insurance companies, such as the Colorado based insurance company, Pinnacol.
4. In the event you are unable to work due to a work-related injury, your employer or the workers compensation insurance company owes you 2/3 of the average weekly wage of your salary which is temporary total disability benefits. In the event your employer or the workers compensation insurance company admits for these benefits, they must pay you at least once every two weeks.
5. The Colorado Rules of Evidence apply in all Colorado workers compensation cases as well as all Colorado personal injury cases. Therefore, if you proceed to hearing in a Colorado workers compensation case or to trial in a Colorado personal injury case and you have not been to law school, you will probably lose.
6. Until recently, a Colorado claims adjuster could pay benefits that you would have received from your Colorado personal injury claim directly to your medical providers who are asserting a subrogation or reimbursement interest possibly leaving you with no monetary compensation for your injury. A Colorado law that went into effect August 11, 2010 limits the ability of a Colorado insurer to obtain a repayment of benefits, through reimbursement or subrogation, if the repayment would cause the injured party to not be fully compensated. Additionally, if the injured party has been fully compensated and the repayment is allowed, the amount of the repayment is limited to the amount actually paid by the insurer or, 80% of the usual and customary charge for the same service charged by health care providers that provide the same care in the geographic region. Finally, an insurer must pay its proportionate share of attorney fees and costs incurred by the injured party in obtaining the settlement or judgment.
7. If you suffer an injury in Colorado from a fall or due to a car accident, and you obtain a recovery that is less than the total amount of coverage available under any third-party liability insurance policy or uninsured or under insured motorist coverage, you are presumed to be fully compensated. A rebuttable presumption that an injured party has not been fully compensated is created if the injured party makes a recovery that equals the amount of coverage available under all third-party liability insurance policies and uninsured and under insured motorist coverages. Further, when an injured party obtains a judgment, the amount of judgment is presumed to be the amount necessary to fully compensate the injured party.
8. If you are injured due to the negligence of a third-party and receive medical treatment, and you also receive monetary compensation that is less than the sum of all your damages, you must notify the insurance company that is seeking reimbursement of your medical expenses that you intend to limit their ability to obtain repayment within sixty (60) days after obtaining each monetary recovery. The notice must specify the total amount and source of the monetary recovery, any applicable coverage limits, and the amount of costs charged to the injured party.
9. In the past, a Colorado claims adjuster’s salary could be based on the number of
policies canceled, the number of times coverage is denied, the use of a quota limiting or restricting the number or volume of claims and the use of an arbitrary quota or cap limiting or restricting the amount of claims payments without due consideration of the merits of the claim. As of May 17, 2010, these claims practices are defined as an unfair compensation practice and a deceptive act or practice in the business of insurance.
10. When you experience a job-related injury in Colorado, your employer or the insurance company should provide you with a list of at least two designated physicians from which you can choose a treating physician. However, there are limitations and requirements concerning this request. First, the employee must complete all requests within ninety (90) days following the date of injury. Also, the injured worker must complete the request prior to reaching maximum medical improvement (MMI). Finally, the change of physician is limited to another physician on the designated list.
11. If you are an injured worker in Colorado, and you settle your case with the claims representative or attorney representing the employer and the employer’s insurance company, you must receive the lump sum settlement within fifteen (15) days after the employer or insurance company receives the signed settlement order.
12. In Colorado, when you are injured at work and obtain maximum medical improvement (MMI), you have a right to see an independent doctor who is assigned by the Colorado Division of Workers Compensation (the Division) in the Department of Labor and Employment. This doctor does not work for your employer or your employer’s workers compensation carrier. The Division provides you with a list of three physicians. Prior to making a determination of which physician you don’t want, the injured worker may request and is entitled to obtain and review a summary disclosure of any business, employment, financial or advisory relationship between a listed physician and an insurer, self-insured employer or claimant.
13. With regards to workers compensation claims, an insurer, self-insured employer,
health care provider or employee or contractor of an insurer, self-insured employer or health care provider is prohibited from paying or receiving any form of monetary compensation that is based on any of the following; the number of days to maximum medical improvement, the rate of claims approved or denied, the number of medical procedures, diagnostic procedures or treatment appointments approved, or any other criteria designed or intended to encourage a violation of the “Workers’ Compensation Act of Colorado”. Payment of remuneration based on any such factors constitutes an unfair or deceptive practice in the business of insurance and subjects the insurer or self-insured
employer committing the violation to penalties under the unfair or deceptive insurance practices statutes, which may be up to $3,000 per violation, not to exceed an aggregate penalty of $30,000, or, in the case of knowing violations, up to $30,000 per violation, not to exceed an aggregate penalty of $750,000 annually.
14. If you are injured on the job in Colorado, and your authorized treating physician
recommends medical maintenance benefits, and those benefits are unpaid and contested are either admitted fewer than twenty (20) days before the date of the hearing or ordered after an application for hearing on the benefits is filed, the court is required to award all costs, not including attorney fees, to you.
15. When you are injured at work, and make a Colorado workers compensation claim, your employer or workers compensation insurer can request that you attend an independent medical examination (IME) with a physician whom they choose. This is different from a Division Independent Medical Examination (DIME). For all workers compensation claims filed after August 5, 2009, the physician selected by the employer or workers compensation insurance company must record the examination. The injured worker also has a right to record the examination. You may request the recording, and if the recording is inaudible or the physician fails to record the examination, you may attempt to strike the IME.
