The insurer has thirty (30) days to accept or deny a workers’ compensation (“WC”) claim filed by an injured worker. Once the injured worker’s claim has been accepted, what next? The insurer will send out the claim acceptance via certified mail, and the claim acceptance will state what body part is accepted under the claim. What body parts are covered is commonly referred to as the “scope” of the claim.
However, if the body part is not included, then it is not part of the claim. This claim acceptance must be appealed by the injured worker within seventy (70) days in order to preserve the injured worker’s rights under the claim, as the claim acceptance or “scope” is rarely determined thirty (30) days after the accident and injury has occurred because the medical prognosis is going to be uncertain at that time.
For example, most spinal fusion surgeries that occur from a work injury generally start out diagnosed as a “lumbar strain” or “cervical strain” even though the scope expands as the claim progresses.
However, if the injured worker does not appeal the original claim acceptance, the injured worker runs a significant risk of not being able to expand the scope of the claim, putting their current and future health at risk. This is one of the most litigated areas in WC claims, and also one of the most important.
However, what body parts should be accepted and to what extent is not always easy to determine early on in the claim. Symptoms can also manifest later on in the claim.
When do body parts and symptoms need to come to fruition to be included under the claim?
In Nevada, symptoms do not have to be instantaneous, but must manifest themselves within a reasonable time. American International Vacations v. MacBride, 99 Nev. 324, 661 P.2d 1301 (1983).
Once the claim acceptance has been appealed, it is important for the injured worker to keep all of his or her medical records in order and up-to-date. The injured worker should also document any new body parts that may arise as a result of the original injury as well as any symptoms that may appear over time. This can be accomplished through doctor’s notes, physical therapy notes, and any other medical records that are pertinent to the claim.
When to file a Workers’ Comp Claim?
In the event of a workplace injury, it is important to file a workers’ compensation claim as soon as possible. It is recommended that an injured worker contact an experienced workers’ compensation attorney or the state workers’ compensation office in order to properly file their claim. All required paperwork should be completed and submitted within the allotted timeframe, as specified by the applicable laws.
The injured worker should also contact their employer to inform them of the injury. Once the claim is accepted, it is important for the injured worker to follow all instructions regarding treatment and rehabilitation, as well as any deadlines set forth by the insurance company.
File a workers’ comp claim with these steps
1. Report the injury to your employer and seek medical attention as soon as possible.
2. File a claim: After seeking medical services, you should then file a workers’ compensation claim with the state or federal workers’ compensation agency in your state. It is important to fill out all necessary paperwork correctly and in a timely manner.
3. Once the claim is accepted, it is important for the injured worker to follow all instructions regarding their treatment and rehabilitation. This includes any deadlines set forth by the compensation insurance company regarding medical appointments or paperwork. It is also important to keep all documentation up-to-date and in order related to the job injury.
4. Seek legal advice: If there are any questions or disputes during the process of filing a workers’ comp claim, it is recommended to seek legal advice from a qualified attorney who specializes in workers’ compensation law.
5. Appeal: If the claim is denied or rejected, the injured worker can appeal the decision and have the case reviewed by an administrative law judge. It is important to file any appeals within the allotted time frame in order to preserve your rights under the claim.
What benefits am I entitled to?
After a workers’ compensation claim is accepted, the injured worker is typically entitled to medical benefits and wage replacement benefits.
- Medical care benefits cover all necessary medical treatment expenses related to the injury, including hospital stays, surgery, medication, physical therapy and doctor visits.
- Wage replacement benefits provide partial or total compensation for lost wages while an injured worker is unable to work due to their injury.
In some cases, an injured worker may also be entitled to vocational rehabilitation benefits and permanent disability benefits. Vocational rehabilitation includes job retraining or education in a new field, while permanent disability benefits provide compensation for any permanent impairment caused by the injury.
What If My Workers’ Comp Claim Is Denied?
If an initial claim for workers’ compensation is denied, it does not mean the injured worker cannot receive any benefits. The first step is to file an appeal of the decision. Depending on the state, there are different procedures for appealing a denied claim, so it is important to contact an experienced workers’ compensation attorney who can assist with the process.
The next step is to contact an experienced workers’ compensation attorney at Shook & Stone for assistance. An attorney can help evaluate the claim and provide advice on how to best pursue your compensation benefits.
Our Las Vegas workers’ compensation attorney may also be able to negotiate with the insurance company or other involved parties on behalf of the injured worker in order to reach a satisfactory outcome. Contact us today by calling (702)570-0000 for a free evaluation.