Questions your claims adjuster may not want to answer
Q: If I am injured at work in Colorado, can I go to the doctor I want to?
A: Your employer has the right to select the medical provider or authorized treating physician that you must use. Most employers should provide you with a list of approved medical providers (a designated provider list). You may choose a treating doctor from this list. If your employer does not properly designate a medical provider, you have the right to choose your own medical provider. Bear in mind, that whether your employer chooses a doctor or you do, once that choice is made, the doctor cannot be changed without the insurance company’s consent. After the claim is filed, the insurance company may request that you be examined by another physician of its choice, and at its expense. In the event you do not go to the examination, you could be subjected to penalties, and the insurance company may ask the Division for permission to stop your benefits.
Q: What if I miss a doctor’s appointment?
A: In Colorado, if you fail to appear at an appointment with one of your authorized treating physicians, you may be sent a notice of a rescheduled appointment. The insurance company may stop your benefits without a hearing if you do not attend the rescheduled appointment. In the event you believe that the insurance company was wrong when they terminated your benefits, you can request a mediation or prehearing conference to assist in resolving the dispute without a hearing or you may request a hearing.
Q: Will my doctor’s bills be paid by the insurance company?
A: Once the insurance company files an Admission of Liability in Colorado, or a final order for medical benefits has been awarded in your case, your workers’ compensation doctors should seek financial reimbursement from the insurance company. It is illegal for you to be billed for the cost of their services or for the difference between what has been charged and what the insurance company paid. Your doctors should send all their bills directly to the insurance company with the insurance company’s claim number included. If you are billed for authorized medical services, you should forward it to the workers’ compensation insurance company with the insurance company’s claim number included. After the bill is forwarded to the insurance company, the claims adjuster is required to make payment or provide notification of the reason for nonpayment within 30 days.
Q: What medical expenses arising from my Colorado work-related injury does the insurance company pay for?
A: The workers’ compensation insurance company pays for all reasonable and necessary medical expenses provided you receive care from a designated doctor or one who is authorized to provide care. If the workers’ compensation doctor refers you to another doctor for treatment for your injury, and the treatment is reasonable and necessary, this medical treatment will also be covered. In addition, you will be reimbursed for all reasonable and necessary medical equipment, supplies, and prescriptions. You should also receive reimbursement for mileage to and from medical appointments. If you go to a doctor who is not authorized, the workers’ compensation insurance company probably will not reimburse you for those medical bills.
Q: What if my Colorado workers’ compensation claim is denied?
A: The workers’ compensation insurance company may deny your claim for a variety of reasons. If the claims adjuster does not believe your injury is work-related or if it is believed that they do not have complete and accurate information and further investigation is necessary, the insurance company will deny your claim. The insurance representative will then file a Notice of Contest. When the workers’ compensation insurance company denies your claim, you are responsible for all medical bills arising from your illness or injury. If you have private health insurance, you may then be eligible for coverage under your private healthcare policy. If the insurance company continues to deny your claim after you have discussed your case with the adjustor, you may have no choice but to apply for hearing. Attorney Mary E. Jeffers will assist you with this process and provide aggressive representation at hearing.
Q: What if my Colorado work injury was caused by another party instead of my employer?
A: If you are harmed in the course and scope of your employment, you are entitled to workers’ compensation benefits, regardless of the cause. In Colorado, you can also sue the third-party that caused the injury such as the negligent driver, or the manufacturer, distributor or seller of the faulty equipment that caused the injury. If your co-worker caused the injury, you cannot sue him or her in Colorado. If you recover from a third-party, the workers’ compensation insurance company is eligible for workers’ compensation reimbursement, and they are able to join you in the suit.
Q: What type of injuries or diseases are covered under Colorado workers’ compensation?
A: Virtually every type of work-related injury and injuries arising from occupational exposure are covered by workers’ compensation. Some of the most common industrial injuries that are covered are bodily reactions to substances, wounds, traumatic injuries, back injuries, and repetitive-stress injuries (RSIs) like carpal-tunnel syndrome (CTS). Colorado also covers mental or emotional harm, including depression, providing it arises from the work injury. Preexisting injuries are not covered unless they are aggravated at work.
Q: How does the insurance company determine how I will be financially compensated for my wage loss?
A: The method by which the insurance company calculates your average weekly wage is determined in Colorado by the adjustor. This calculation results in your wage loss benefits, and what you will receive for your time off work. If you are unable to work at all due to doctor’s restrictions, you are entitled to receive two-thirds of your average weekly wage in temporary total disability benefits up to a legal cap. The monetary value of fringe benefits, such as free meals, should also be included in the calculation of your average weekly wage. In the event you employer-paid medical insurance is terminated because you are off work, the value of that insurance should be included in you average weekly wage. Cobra letters are useful in determining the value of your employer paid medical insurance. If you have questions on the calculation of your average weekly wage, call the Law Office of Mary E. Jeffers.
Q: How can I see an independent doctor in Colorado who isn’t being paid by the workers’ compensation insurance company?
A: Once your condition has stabilized and ceased to improve and you are placed at maximum medical improvement (MMI) by the workers’ compensation doctor, you can request a Division Independent Medical Examination (DIME). A level II state trained accredited physician will evaluate your medical condition, and probably determine your permanent impairment. The cost of this examination is usually $675.00 and is paid by the party requesting the DIME. If you are unable to pay, you may request that a judge of the Office of Administrative Courts determine whether you meet the financial requirements for indigence. In most cases, if you are unable to afford a Division Independent Medical Examination, Attorney Mary E. Jeffers will front the cost of the DIME.
8690 Wolff Court
Westminster, CO 80031