Answers to Workers’ Compensation Questions From a Columbus Attorney
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General Workers' Compensation Claim FAQs
Columbus employees and workers throughout Ohio who suffer injuries on the job normally have many questions running through their mind. Here we have provided many answers to common questions we are asked regarding general claim information. We have also provided many questions and answers regarding medical treatment and receiving compensation.
- Who is responsible for filing an Ohio workers’ compensation claim?
- Do I qualify for workers’ compensation benefits?
- What kind of injuries are covered by workers’ compensation?
- Do I need an attorney for my workers’ compensation case?
- How do I claim workers' compensation?
- How long does it take to process a workers’ compensation claim?
- What types of benefits will I receive?
- What is a C84?
- What’s a MEDCO-14?
- What is permanent partial disability?
- If my injury happened at work, why is my employer denying treatment?
- What if my employer tells me not to file a workers' compensation claim?
- Can I appeal a denied workers' compensation claim?
Who files an Ohio workers’ compensation claim?
You do! When an injury occurs at work, immediately report the accident to your employer. They are supposed to help you file the claim with the company’s Managed Care Organization (MCO). Reporting the claim on the BWC website is the Bureau’s preferred way of filing a claim. When you file a claim online, you will immediately receive a claim number. Learn more about filing a claim if you have already seen a doctor.
Do I qualify for workers’ compensation benefits?
Unfortunately, the answer is not so simple. Workers' compensation laws are very complex and it is sensible to work with an experienced Columbus workers compensation attorney. It really does depend on your individual situation. Please call our office at (614) 334-4649.
What kind of injuries are covered by workers’ compensation?
In Ohio, workers’ compensation covers physical injuries sustained in the course of and arising out of employment. Pre-existing physical conditions substantially aggravated by a work injury/incident may also be covered. Psychiatric/psychological conditions that develop from or, if pre-existing, are substantially aggravated by physical injuries are also covered. Ohio is one of a minority of states that does NOT recognize as compensable psychiatric/psychological conditions that develop without a corresponding physical injury.
Do I need an attorney for my workers’ comp case in Columbus?
Not all claims involve serious injuries and not all claims need attorney involvement. If an injury is relatively minor, requiring maybe a trip to the emergency room and a stitch or two with no residual impairment, it may go through without a hitch. It’s likely you will want to talk with a Columbus attorney who specializes in workers’ compensation claims if your injury is serious, will likely involve lost-time from work, and/or is being contested by your employer and/or the BWC. Learn more
How do I claim workers' compensation in Columbus?
First, report the injury to your Columbus or Ohio employer in writing. While reporting in writing isn’t a legal requirement, doing so documents your actions and lessens the possibility that your claim will be contested. Second, seek medical attention from an urgent care facility, hospital emergency room, company nurse, or doctor soon. Provide a complete history of what you were doing, how you were injured, and where it hurts. Third, if you are claiming workers’ compensation, file your claim promptly. The time you have to file a claim is limited by the statute of limitations. Your hospital or employer may furnish necessary paperwork and even file the claim for you, but it is ultimately your responsibility to ensure that your claim is filed with the Ohio Bureau of Workers’ Compensation and a claim number is assigned.
How long does it take to process a workers’ compensation claim?
Within 28 days, the Bureau of Workers’ Compensation (BWC) will allow or deny your claim. By responding to any inquiries from them or from your managed care organization (MCO), you will speed up the decision process and receipt of benefits.
What types of benefits will I receive?
Injured workers in Ohio are eligible to receive medical treatment for their work-related injuries and compensation for their lost time from work. This compensation, known as Temporary Total Disability (TTD), is paid if the injury results in more than a week off work. If the lost time is less than a week, no compensation is payable. If it’s between one and two weeks, only the period during the second week is compensable. If over 2 weeks, it’s all paid.
Temporary Total Disability compensation is paid based on a percentage of the worker’s earnings for one week, 6 weeks or 52 weeks prior to the injury, depending on how long the period of disability lasts. Injuries resulting in some permanent impairment may permit an additional award of compensation known as permanent partial disability.
What is a C84?
The Ohio Bureau of Workers’ Compensation requires Form C84 as proof of ongoing temporary total disability. The injured worker must complete the form, verifying the period of disability and that she has not worked and has not received other wages during the period of temporary total disability. These forms must be periodically updated for compensation to continue. Your doctor must complete a separate form certifying temporary total disability. Both forms are required before compensation can be paid.
What’s a MEDCO-14?
A MEDCO-14 is a Physician’s Report of Work Ability. Your doctor completes this form to certify that you are temporarily and totally disabled due to your work injury or to identify any restrictions on your ability to perform your job duties due to the injury. A MEDCO-14 must be submitted every time you submit a C-84.
What is permanent partial disability?
Permanent partial disability (PPD) is a form of compensation that may be payable following a work injury. It is paid by the Ohio Bureau of Workers’ Compensation or a self-insured employer following an exam (or sometimes multiple exams) at which a physician is asked to provide an opinion regarding lost bodily function that has resulted from an injury or occupational disease. It is workers’ compensation’s version of a damages award for an industrial injury. Time limitations may apply in requesting an award of PPD. In addition, the percentage of disability resulting from an injury may be disputed by the injured worker, the employer, and/or the BWC. In such situations, the Industrial Commission conducts a hearing to determine a proper award. This is differs from a settlement of your claim.
If my injury happened at work, why is my employer denying treatment?
Treatment may be denied by your employer, your managed care organization (MCO), or the BWC if excessive, inappropriate, or not cost-effective. MCOs may deny treatment they consider too expensive, even if it is treatment your doctor believes is beneficial. You may appeal decisions denying treatment that your doctor believes appropriate.
What if my employer tells me not to file a workers' compensation claim?
Penalties may be assessed against employers who fail to provide workers’ compensation coverage. If an employer tells you not to file a claim for a work-related injury, maybe s/he tried to cut costs by not obtaining the mandatory workers’ compensation coverage. Reporting the injury would notify the BWC of the employer’s non-compliance. It could also be the employer has had so many claims filed against them they fear the BWC will increase their insurance premiums.
Injured employees are still covered by the workers’ compensation system even if their employer is non-complying, so it is still best to file a claim. Learn more
Can I appeal a denied workers' compensation claim?
The BWC has 28 days to allow or deny your claim. If you or your employer disagrees with BWC’s decision, either party can file an appeal with the Industrial Commission (IC) within 14 days.
There are three hearing levels for workers’ claims at the IC:
• District level hearings — These take place in locations throughout Ohio within 45 days of filing an appeal. The district hearing officer will decide within seven days. The IC sends both parties a written notice of the hearing officer’s decision. Each party has 14 days from receipt of the district hearing officer’s decision to file an appeal to the next level.
• Staff level hearings — These take place within 45 days after an appeal of the district hearing officer’s decision is filed. The staff hearing officer will decide within seven days. The IC will send each party a written notice of the staff hearing officer’s decision. Each party has 14 days from receiving the staff hearing officer’s decision to file an appeal to the next level.
• The commission level — After studying the staff hearing officer’s decision, the commission either agrees to hear the appeal or refuses to permit further appeal. If the commission accepts the appeal, a commission hearing will occur within 45 days. The commission will decide within seven days. If the commission refuses to hear the appeal, depending upon the issue, you may appeal the matter to the court within 60 days after receipt of the commission order. Learn more about your options if your workers' comp claim has been denied.
Medical Treatment FAQs
It only takes a split second for an accident at work to turn a person’s life upside-down as the medical bills roll in. We've aimed to answer all of your questions regarding receiving the medical treatment you need. If you still have questions about workers' compensation or receiving medical treatment, please contact our office at (614) 334-4649. We've also answered many FAQs regarding general claim info and receiving compensation.
- Who approves treatment?
- Can I go to my family doctor?
- I want to change doctors. How?
- I can’t get my prescriptions filled. What should I do?
- What is MMI?
- Why do I have to wait for treatment?
- What is Independent Medical Examination (IME)?
- How will I know if a doctor is certified by BWC?
- How do I get my medical bills paid for?
- What should I do if I get medical bills?
- Can I get reimbursed for prescriptions?
Who approves treatment?
Requests for treatment are submitted by your doctor to the MCO assigned to your case. If your employer is self-insured, requests are sent to your employer’s TPA (third-party administrator). The MCO or TPA may request additional information from your doctor or a medical review before approving the treatment. Denials of treatment may be appealed.
Can I go to my family doctor?
An injured Ohio worker may be treated by a doctor of his choice, as long as the doctor is a BWC-certified healthcare provider. Often, family doctors do not treat job-related injuries because they are concerned about the paperwork involved and/or the hassles associated with claims procedures. Your family doctor refer you to a BWC-certified provider. You can also ask for recommendations from co-workers, your union representative, your attorney, or other people who have received treatment for a work injury. The BWC and your MCO also maintain lists of physicians who treat industrial injuries.
I want to change doctors. How?
You may decide to change physicians for a variety of reasons, ranging from the retirement of the provider, travel distance, or a desire for a different treatment option. Injured workers who wants to change physicians should notify the MCO and submit BWC Form C23. If your employer is self-insured, this form should be sent directly to the employer or its TPA.
I can’t get my prescriptions filled. What should I do?
Your pharmacist can explain why payment for a prescription is denied. It may be a coding error or a concern that the medication is inappropriate. Your doctor can provide additional information regarding the need for and the propriety of the medication. If the bill was denied pending the allowance of the claim, you will be reimbursed once your claim is allowed. Keep all receipts for medications and treatment related to your injury if you need to request reimbursement.
What is MMI?
Temporary total disability (TTD) compensation is payable following an on-the-job injury until the injured worker is released to return to her former job, actually returns to that job, or is determined to have reached maximum medical improvement (MMI). MMI indicates that the injury has reached a treatment plateau under the current treatment regimen, meaning it has gotten about as good as it will get! Although temporary benefits are no longer payable if the condition is no longer improving, other forms of compensation may be available for injured workers whose TTD has been terminated after a finding that their condition has reached MMI.
Why do I have to wait for treatment? I just want to get back to work!
During the initial processing period (i.e., when the Ohio BWC or your employer is deciding whether to allow or contest the claim), physicians may be reluctant to provide treatment, as there is no guarantee they will be paid. Some doctors will provide treatment, pending the allowance of the claim, expectating the claim will be allowed or that you have other means of paying (for example, other insurance) should the claim be disallowed. While your claim is considered, avoid large unpaid medical bills you may have to pay should your claim be disallowed. Once the claim is allowed, providers (other than pharmacies) who have treated you for the job-related injury should submit their bills to your MCO.
What is an Independent Medical Examination (IME)?
An independent medical examination (IME) is a medical evaluation scheduled by the BWC or employer's representative to opine about various medical issues related to your claim, including, but not limited to, whether treatment or testing is necessary, the degree of your permanent impairment and whether you have reached MMI. When scheduled by an employer, I believe it more accurate to describe this as a DME: Defense Medical Exam. Employers hire the same doctors over and over to render medical opinions on their behalf--they are not "independent".
How will I know if a doctor is certified by BWC?
The simplest way is to ask your doctor when you make the initial appointment. You may also call the employer's MCO, the BWC at 1-800-644-6292, or research BWC certified providers (by name, location and/or specialty) at the BWC's website.
How do I get my medical bills paid?
Medical bills should be payable in an allowed claim. Give your claim number to all of your medical providers who treat you in your claim. They will then request authorization for the medical treatment they request from the MCO. There are advantages of using the workers' compensation system as opposed to using private health insurance for a work injury.
What should I do if I get medical bills?
You should forward the bills to your MCO or self-insured employer. Unpaid bills can be appealed to the BWC for further investigation.
Can I get reimbursed for prescriptions?
Like medical bills, prescriptions for allowed conditions in your claim should be payable in an allowed claim. Inform your pharmacist that the prescription is for a workers' compensation claim. You may need to pay for the initial prescription, but if the BWC determines the medicine was for the allowed conditions, you will be reimbursed.
Obviously, you are responsible for any bill or prescription that the BWC determines is not related to your claim.
Workers who suffer injuries on the job normally have many questions running through their mind. Here we have provided answers to the questions we are commonly asked. We have also provided many questions and answers regarding medical treatment and general questions.
- When will I get paid? How much will I be paid?
- How long can I get paid for missing work?
- What decides how much money I receive while out of work?
- Can I ask for a settlement?
- What happens if I go back to work after being deemed permanently and totally disabled?
- Do I still get any benefits when I return to work?
- Is any tax taken out of my benefits check?
- Why do my Worker's Comp checks come in for different amounts?
- How long does it take for me to receive my benefits check?
When will I get paid? How much will I be paid?
Filing a claim doesn’t guarantee payment of compensation or benefits. Your claim may be denied or disputed by the BWC or your employer. The Ohio Bureau of Workers’ Compensation has 28 days from claim filing to accept or deny a claim. Learn about your options if your claim has been denied. Compensation won’t be paid until a claim is allowed.
The amount you are paid depends in part on how long you cannot work. The Ohio BWC or a self-insured employer will calculate your earnings prior to your injury, and you will be paid a percentage of those wages. The wage calculation and rate of payment often change, depending upon how long you cannot work. Wages may be set too low, and in these cases we can request an adjustment to consider special circumstances, periods of unemployment, or additional wage information, including wages from a second job.
How long will I be paid for the work I miss?
Generally, you could be compensated until you are released to return to your former job, actually return to that job, or are determined to have reached maximum medical improvement (MMI).
How is the money I am paid determined?
Your benefits are based on the money you earned working for the year prior to injury. Your Full Weekly Wage (FWW) is determined by the greater of your gross wages (including overtime) earned over the 6 weeks prior to injury, divided by 6; or your gross wages (excluding overtime) for the 7 days before the injury. The first 12 weeks of temporary total disability (TTD) compensation will be paid at 72% of your FWW. Benefits after the first 12 weeks of TTD will be paid based on your Average Weekly Wage (AWW), which is generally calculated by taking your earnings from all employers for the year prior to the injury and dividing that amount by 52 weeks. Those benefits are paid at 66⅔% of your AWW.
Can I ask for a settlement?
This is an issue you should consult an attorney about. There may be factors you are not aware of, and an experienced attorney can help secure the maximum settlement amount. At a minimum, wait until you are sure you will have no further complications from your work injury. Most employers will not settle with an employee while they are still working there, as the risk of re-injury and a new claim is present.
What happens if I go back to work after being deemed permanently and totally disabled?
You will lose any permanent total disability (PTD) benefits and likely be charged with fraud if you collect PTD compensation while working (unless you are receiving statutory PTD). If you believe you have medically recovered to the point of returning to work, consult an attorney about options before you do.
Do I still get any benefits when I return to work?
There are other benefits that may be available after returning to work. For instance, you may be entitled to a Working Wage Loss if your injury prevents you from making the same salary as you did prior to the injury. This is something you should consult with an attorney about.
Is any tax taken out of my benefits check?
No. Workers' compensation benefits are tax-free.
Why do my Worker's Comp checks come in for different amounts?
The first 12 weeks of TTD compensation are paid at 72% of your FWW. After the first 12 weeks, it is paid at 66⅔% of your AWW. It is possible that, because of the day of the week a check is originally issued or other factors, a check may only cover a portion of the standard 2-week pay period. The period covered will be listed on the payment. You will receive the amount you are entitled to, and eventually, the checks will be for a consistent amount and released on a consistent basis.
How long does it take for me to receive my benefits check?
Unfortunately, there is no definitive answer to this question. It may take many weeks (and sometimes, months) before compensation is received after it is awarded.
As a worker on a family-owned farm, can I get workers’ compensation if I’m hurt on the job?
Every employer in Ohio must carry workers’ compensation insurance. This includes small farms and orchards with only a few seasonal employees—even if those employees are family members.
If you're hurt on the job, and your employer has the required insurance, you'll file a claim with the Bureau of Workers’ Compensation (BWC).
What If My Employer Doesn’t Have Workers’ Comp Insurance?
Small farms rarely turn much of a profit, and survival is often a matter of cutting costs to the bone. If the farm owner where you work hasn't paid into the state fund to save money, they'll be fined—and more—by the BWC.
However, this won't affect your ability to collect the compensation you're entitled to receive from the BWC. The BWC has funds set aside just for this purpose. That your employer doesn't have workers’ comp also opens the door for you to sue them if your injury was caused by faulty equipment or other negligence.
What If I’m Told to File With My Health Insurance?
If you have health insurance, your uninsured employer might suggest you get medical treatment through that policy. This is a problem.
Under Ohio law, on-the-job injuries must be compensated through workers’ comp, not health insurance. To cover treatment by health insurance, you would have to lie to your doctor about the cause of your injury, and then you and your employer would be breaking the law. You could also lose your health insurance.
Farms With No Employees
For farms, the only exceptions to the workers’ compensation requirement in Ohio are sole proprietors, partnerships, or family-farm corporate officers with no employees. So, for example, if you own a small commercial farm but only you and your spouse do the work, you're not required to carry workers’ comp insurance.
However, if one of you is injured, your health insurance company could deny your claim because the injury was work-related. With no insurance coverage, one serious injury could be enough to bankrupt the farm. For this reason, it's a good idea for even owner-operated farms to carry elective workers’ comp insurance.
If You're Getting the Runaround, Call Us!
If you're hurt while working on a farm and your injuries are serious enough to require medical treatment and keep you away from work for an extended period, you're entitled to file a workers’ comp claim under Ohio law.
If your employer is trying to persuade you not to file, we suggest you talk to a workers’ comp attorney. You should have comprehensive medical treatment and lost wages, which you will get no other way. The team at Monast Law Office will help protect your rights and ensure you get the care you need after an injury at work. Call us or fill out the form on this page today.
What does the Bureau of Workers' Comp mean by maximum medical improvement?
Sometimes, an injured worker will never recover completely from a work-related injury but, if they were awarded workers’ comp temporary total disability (TTD) benefits, these are payable until the employee has healed as much as they're going to.
This point of recovery is called maximum medical improvement (MMI), and it's an important milestone in a workers’ comp claim.
How Maximum Medical Improvement Is Determined
The goal of TTD benefits is to allow an injured worker to get the medical treatment and time off work they need to recover and return to work. Your physician of record may determine, based on a medical assessment, you reached this point after treatment and sufficient recovery time. This doesn't necessarily mean you are able to return to your former job or that you're able to do what you did before the injury. Regardless, TTD benefits stop when you reach MMI, as determined by one of the following:
- Physician of record. When your workers’ comp doctor decides that your recovery has plateaued and you will not get any better, the Bureau of Workers’ Compensation (BWC) or the self-insured employer is informed and will terminate TTD benefits as of the date indicated by the doctor.
- Independent Medical Exam (IME). If it's determined at one of your periodic medical exams that you have reached MMI, it will be reported to the BWC, which confirms the conclusion with your physician of record. If the doctor agrees, your TTD benefits will be terminated.
- Ohio Industrial Commission. If your physician disagrees with the IME conclusion, the BWC will refer the case to the Ohio Industrial Commission (IC) to make the final determination. You and your attorney will be notified of the date for the hearing. If the IC decides that you have reached MMI, you can appeal the decision.
If your TTD benefits were terminated because you have reached MMI, you still have options. If you return to work making less money than you did before, you might be eligible for wage loss benefits. If you can’t return to any work, you might qualify for permanent total disability benefits. You could also qualify for a retraining program.
Let Monast Law Office Help You
I've been practicing workers’ comp law in Ohio for over 35 years. If you were told you have reached maximum medical improvement, you need help understanding what that means and your options. Request my free guide, The Worker’s Guide to Injury Compensation in Ohio, and then contact my Columbus office to talk to someone who can help.
Unum denied my claim for long-term disability. What can I do?
If you work for Ohio State University, Wendy’s International, or Worthington Industries, and you opted into their long-term disability (LTD) insurance coverage, you probably have a policy with Unum Group. When a huge international insurance company like Unum denies your claim, you shouldn't attempt an appeal without the assistance of an ERISA attorney.
Monast Law Office would be happy to review your claim and discuss the possibility of an appeal.
Your Attorney Will Help You Throughout the Process
When Unum denies your claim, you have a right to appeal. While the Employee Retirement Income Security Act (ERISA) guarantees this right, it also requires that you follow a rather complicated and restrictive process.
When appealing a Unum denial, we recommend that you:
- Call an attorney. Not every disability attorney accepts claims involving ERISA, but it's important that you find one who does as soon as you receive an adverse benefits decision.
- Understand your policy. Many claims are denied because the condition that caused your disability is excluded or is considered pre-existing. Knowing what's excluded in your policy before appealing saves you time and money.
- Work on your appeal immediately. ERISA limits the time you have to file a complete appeal. Your attorney knows of these deadlines.
- Get your claim file from Unum. You and your attorney can review the file to see what you’re up against in trying to win an appeal. What was the denial based on? Did Unum correctly represent your job duties? What evidence does it have? All of this information is in the file.
- Gather your evidence. You'll have to stack your Unum appeal with an abundance of evidence proving that you're unable to work, have seen doctors, and followed treatment plans. You only get one opportunity to present this evidence, so your attorney will make sure your appeal is loaded with the appropriate information.
If this process sounds stressful and overwhelming, that’s because it is. However, when you work with an attorney experienced with ERISA appeals, you don’t have to carry the burden alone.
Request Our Free Guide to ERISA Claims
You’d have to be an insurance adjuster to know all the tactics an insurer will use to deny your long-term disability claim, but you can understand more about what you’re up against by calling my office and by downloading and reading my free resource, How Insurance Companies Sabotage Disability Claims. If your LTD claim has been denied, please contact Monast Law Office for help.
Should I take a lump-sum payout for my long-term disability claim?
When you suffered a catastrophic injury and could not work, it might have been a struggle to get the long-term disability (LTD) benefits to which you were entitled. Now that your claim is approved, an important decision in the next part of the process is whether you want to payments over time or in one lump sum. The insurance company will do what costs the least money, so if it's offering a lump sum, consider several factors before you accept.
Advantages of a Lump-Sum LTD Payment
The biggest advantage of accepting a lump-sum payment is that it ends your relationship with the carrier. Rather than dealing with the company over a period of months or years as you get monthly payments, you'll receive one payment and be done with the process once and for all.
A lump-sum payment is also helpful if you have substantial and immediate financial needs—such as altering your home to accommodate your disability or paying off a high-interest credit card.
The Downside to a Lump-Sum Payment
An important factor you must consider when thinking about a lump-sum payment for LTD benefits is your own spending habits. If you're not good at budgeting and planning for the future and are likely to spend the money all at once on frivolous things, getting a lump-sum settlement is probably not a good idea.
Also, a lump-sum payment will always amount to less than the total you would get over time. Just how much less is another important consideration.
Finally, you might owe income tax on your LTD benefits, depending on how the insurance premium was paid. If you paid for the policy with after-tax dollars, you wouldn't owe income tax. However, if your employer provided the policy or you paid with pre-tax dollars, you must pay income tax. This could have a negative impact if you accept a large settlement in one payment.
Your ERISA Attorney Can Help You Decide
If you worked with an attorney to get the LTD benefits you deserved, your attorney will help you decide whether a lump sum makes sense for you. As an ERISA attorney, I make sure your rights are protected throughout the entire claim process. If you want to learn more about ERISA and long-term disability policies, request a copy of our free book, How Insurance Companies Sabotage Disability Claims.
What is a lump sum advancement—and should I take it?
A workers’ compensation lump sum advancement (LSA) is the pre-payment of future compensation for a specified purpose available to those receiving permanent total disability (PTD) or permanent partial disability (PPD) scheduled loss awards.
While this benefit is intended to help injured workers who have an immediate financial need, it might be a good idea to exhaust other options before taking an LSA.
When You Might Need to Take a Lump Sum Advancement
It’s hard enough to make ends meet when you're working full time, so offering a pot of money to help with expenses when you become disabled is tempting. To qualify for a lump sum advancement, you must also show you need financial relief. According to the Bureau of Workers’ Compensation (BWC), you may request a lump sum advancement for:
- Household expenses. Bills will keep coming, but if you're behind in paying rent, mortgage, utilities, or insurance, it might make sense to take a lump sum to get caught up.
- Emergency expenses. If you need a new roof, a vehicle, an appliance, or have some other major emergency purchase, you can request a lump sum if you submit an estimate and a reason to the BWC ahead of time.
- School tuition. An LSA can pay tuition for the injured worker or their children.
- Adaptive equipment. In some cases, there's an immediate need for a wheelchair, ramp, vehicle modification, or other adaptive equipment. An LSA can be used for that if it's not already covered under your claim.
It's important to understand that the amount you'll get in a lump sum advancement is less than what you would get in the long run if you take regular payments. Also, while you're expected to use the lump sum on the approved expenditure, it's ultimately up to you to use the money responsibly. If you know you're better off with a steady, reliable income stream for years to come, you probably shouldn’t apply for an LSA, even if you're qualified.
Discuss Your Options With a Workers’ Comp Attorney
The purpose of workers’ comp benefits is to pay for medical treatment and replace lost wages due to a job-related injury. When you're awarded permanent total or permanent partial disability benefits and have immediate financial needs, you must make decisions about how to receive those funds. If you need help weighing the pros and cons, contact Monast Law Office for advice. You can learn more about Ohio Worker’s Compensation by requesting a free copy of my book, The Worker’s Guide to Injury Compensation in Ohio.
Cigna denied my disability claim. Can I appeal?
You opted into your employer’s long-term disability (LTD) insurance plan with Cigna for the peace of mind it provided. You thought it would cover you and help your family if you had to take significant time off of work due to an injury or illness. However, your LTD claim was denied, and you don’t know where to turn. Fortunately, it may be possible to appeal Cigna’s denial.
Cigna Is Known for Denying Claims in Ohio
As an insurer for companies like Honda, Cigna is a big player in the Ohio insurance game. Unfortunately, it doesn't always follow the rules. According to a recent study, Cigna and its subsidiaries deny more long-term disability claims each year than any other insurer, and not always for valid reasons. In the last ten years, there have been at least 62 bad-faith court cases filed against Cigna. So if Cigna denied your LTD claim, you're not alone.
What You Should Do If Cigna Denies Your Claim
If your employer provided your Cigna long-term disability insurance, it's probably governed by the Employee Retirement Income Security Act (ERISA). If you have to file an administrative appeal, be prepared for a difficult battle. Your first steps should be to:
- Review the denial letter. You first need to understand why your claim was denied. Under ERISA, Cigna must provide a detailed explanation for the denial and tell you about your right to appeal.
- Gather evidence. Given Cigna’s reason for denying you, the next step is to gather evidence to counter their claims. This might include witness statements, medical records, employment records, and statements from vocational experts.
- Call an ERISA attorney. Not every attorney is equipped to handle ERISA claims. You'll need to find an attorney who is willing to take on Cigna within the constraints of ERISA law.
It’s important to understand you don't have to face Cigna alone. You should have an attorney help you with an appeal.
Monast Law Office Accepts ERISA Appeals
If Cigna denied your long-term disability claim, contact my office in Upper Arlington. I'll review your denial letter and help you launch a successful appeal. To learn more about ERISA claims, request a free copy of my book, Don’t Go it Alone: How Insurance Companies Sabotage Disability Claims.
What is an adverse benefit decision on a long-term disability claim?
If you file a long-term disability (LTD) claim on your employer-sponsored policy and the insurance company denies or terminates your application, pays less than the claim is worth or says you're only entitled to limited benefits, that means they have issued an “adverse benefit decision.” As soon as this happens, you have necessary rights to act on.
But unless you talk to an attorney who handles ERISA claims, you'll have a hard time exercising those rights. Let me explain what I’m talking about.
ERISA Grants You This Important Right
The Employee Retirement Income Security Act (ERISA) is a complicated piece of legislation that protects both employers and employees in situations involving various kinds of benefits, including long-term disability insurance policies. Under ERISA, if you receive an adverse benefits decision, you may get a copy of your claim file to see the information the insurance company used to make the adverse decision.
Now, it won’t just voluntarily hand over the claim file. You'll have to request it in writing and, even though the carrier is required by law to give you the record, it might still deny your request.
How Can You Protect Your Rights?
Maybe the claim manager isn't aware of the law that compels the company to hand over the file, or it could be more intentional than that. Either way, without an ERISA attorney advocating for you, it's unlikely you'll get access to the file, even though the law is on your side. Even if you're able to get the file, it will be difficult, if not impossible, for you to wade through the data and figure out if you have a case for an appeal.
However, an experienced ERISA attorney such as myself has the knowledge and resources to review the file—which could be thousands of pages long—and determine if you have reason to appeal.
Trust Monast Law Office With Your LTD Appeal
As I said before, ERISA protects both you and your employer. While it might grant you some rights, it also limits what you can do with those rights to protect the employer. Your best bet is to call our office when your LTD claim is underpaid or denied. Leave the complicated ERISA laws to us—we’ll make sure your rights are protected. If you want to learn more about ERISA, request a copy of our free book, How Insurance Companies Sabotage Disability Claims.