When you hurt yourself on the job, insurance adjusters and the human resources department team may use various unfamiliar terms. Common questions we get, and you may have, include:
Do not be intimidated. Help for common scenarios.
Common workers’ compensation defense from insurance adjusters:
- The work accident did not happen or occur. In this situation, the adjuster will controvert or contest an accident or injury even transpired. If an adjuster questions the injury, they might suggest you, the injured worker, should not be believed or are somewhat untrustworthy.
- If the facts demonstrate that an accident happened, the insurance adjuster may controvert the claim by asserting that the accident did not happen during your job. Here, the adjuster may assert you were on a break or your physical pain was personal and not caused by your work duties (e.g., a pre-existing condition).
- If the work duties caused it, the adjuster may claim that the injury was not severe and should not keep you from working. In this scenario, the adjuster resists starting weekly income payments or temporary total disability (TTD) benefits.
- If you are disabled, the adjuster may attempt to convince the authorized treating physician, or the ATP, to release you back to work before it is either medically advisable or before you are ready. The adjuster may even attempt to convince the ATP that the disability was because of a reason unrelated to the work injury and accident.
If the insurance company believes it can advance these defenses or theories, it will file the State Board Form WC-3. This filing gives all the parties of interest notice that the insurance company contests its responsibility and will refuse to pay unless ordered to do so by an Administrative Law Judge (ALJ). If you receive a State Board Form WC-3, the insurance company is digging its heels in the sand and daring you to retain a lawyer.
If the insurance company does not have strong defenses, it will simply delay your case in hopes that you will give up and not retain assistance. It will move at a snail’s pace under the disguise or pretense of “investigation.” If the insurance company is taking several weeks or months to approve your medical treatment with the insurance doctor it directed you to see, then the adjuster is hoping that you will simply give up. The adjuster will likely be extremely rude to you or attempt to make you feel like you are a bad person for getting injured on the job.
While there are some timeframes outlined in the law, they are largely forgiven by the State Board with a tremendous amount of leniency (and deference) given to the insurance companies. It is not fair and the injured workers are generally the ones who are expected to suffer the most.
The controvert is the keystone of the defense of workers' compensation claims. It serves as the employer/insurer's shield against fraud and facilitates protection under the law. However, the controvert has also served as the sword turned against the employer/insurer as a basis for an assessment of attorney's fees and penalties. In many occasions, the timeliness of filing the WC-3 or WC-1(c) determines whether the controvert works for or against the insurance adjuster or the claimant.
Challenging the controvert is critical
While the controvert is used often, it is often improperly used and not filed on time. The goal of the controvert is to inform you that the employer/insurer will not provide immediate income or certain medical benefits voluntarily. Generally, the controvert is final unless challenged by the employee. If you challenge the controvert, you request an evidentiary hearing before the State Board to determine whether or not you should be awarded benefits.
If no benefits are paid on the claim, the employer/insurer has 21 days from discovering the asserted injury or disability to controvert the claim. The proper controvert must state the grounds for the denial of benefits. While the law does not provide a list of acceptable reasons to controvert a claim, the Board suggests that using a vague reason such as pending investigation is insufficient. However, under subsection (d) of O.C.G.A. § 34-9-221, the employer/insurer may controvert the claim, initiate an investigation, and then commence benefits, if appropriate. The cost of this approach is a 15% late-payment penalty if it turns out the claim was compensable.
The initial 21 days are calculated from the date of injury or disability. The expiration of the 21 days does not bar the employer/insurer from contesting the claim and does not serve as a statute of limitations. However, the failure of a timely filing of the WC-3 or WC-1(c) opens the door to an assessment of attorney’s fees and administrative penalties.
Many times, a reason for controverting a claim reveals itself after the employer/insurer starts benefits. In those situations, the employer/insurer may controvert the claim in its entirety within 60 days of the date the benefits are due. O.C.G.A. §34-9-221(h). Effectively, the law allows the employer/insurer 81 days from discovery of the injury or disability to challenge the claimant’s entitlement to benefits.
When an injured worker receives the WC-3 Notice to Convert, it is time to contact a lawyer as the insurance company is asserting its right to deny at least one aspect of your claim under the Georgia Workers’ Compensation Act.
Call Our Workers’ Compensation Experts today!
Fight against these insurance tactics. You deserve medical care and income benefits if you were hurt at work. Call Ramos & Law today.
These case studies are not meant to promise or guarantee a certain or similar result, but rather to demonstrate the legal attention and work ethic our attorneys assert in our cases. Every case is different and is fact sensitive. Certain facts can greatly influence and determine a client’s award, outcome, and recovery.
An employee worked for a manufacturer of outdoor power products in Middle Georgia. His job required him to pull pallets of material across the work area. As a result, he experienced a back strain. The manufacturer denied the claim and contested his need for medical care. Ramos & Law was able to secure helpful diagnostic scans and meaningful medical care for the injured worker. After a few months of litigation, the parties reached a settlement of $65,000 with a complete resolution of all outstanding medical bills.
An employee was stocking heavy merchandise for a large retailer in Columbus, Georgia. During the course of her job duties, a stocking cart of the merchandise fell on her right foot and great toe. The national retailer directed her to its company doctors but she received very little relief. The attorneys at Ramos & Law were able to navigate her medical care to more qualified doctors where she received a better overall results. As she reached maximum medical improvement, the large retailer settled the claim for over $100,000 and paid for all of her past medical treatment.
Failed Back Syndrome
An employee was working part-time for a large automotive parts store. The employee fell off a ladder injuring his teeth, neck, ribs, and low back. After exhausting conservative medical care, physical therapy, injection regimens, and medication, it became clear that this injured employee required the need for spinal surgery. While the insurance company fought the surgery, Ramos & Law was able to force the insurance company into paying for the surgery and associated therapies including the implant of a spinal cord stimulator. Given the severity of the injury, Ramos & Law was able to refer the client to a federal disability benefit specialist who assisted him in securing Social Security. This part-time employee settled his case for $185,000 plus almost $300,000 in future medical care.
Low Back Herniations
A pediatric physician injured his back while assisting a child off an examining room table. As a result, the physician herniated several discs in his spine which also triggered depressive mental episodes. While the insurance company denied medical coverage for his numerous symptoms, Ramos & Law was able to secure quality medical care for the employee including orthopedic care, psychiatric treatment, a spinal cord stimulator, and physical therapy. Additionally, the employee received on-going income benefits at the maximum workers' compensation rate. At the end of the case, the matter settled for a figure close to $250,000 in addition to payment of previous medical bills.
An employee at a beverage maker in Atlanta was stocking heavy cases of merchandise when she felt severe neck and shoulder pain. It was revealed that she suffered a torn rotator cuff. While the beverage maker initially denied her medical care, Ramos & Law was able to convince the employer to approve her treatment plan and accept the case. After months attempting to return to work, it was clear that the employer was not able to accommodate her medical limitations. As a result, the case settled for $115,000, along with all her medical bills being paid.
A part-time grocery employee fell into a tub of “degreaser” that caused severe third degree burns over his torso and buttocks region. The employee required immediate medical care and several weeks in the intensive care unit within the local burn center. The costs of the care reached in the millions of dollars. While the grocery store denied liability for the accident, the attorneys at Ramos & Law were able to secure a settlement of $250,000 in addition to the employer’s acknowledgment to pay for all past medical bills.