Answers to Workers’ Compensation Questions From a Columbus Attorney
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I was told I need an ERISA attorney to help with my long-term disability denial. What does that mean, and where can I find one?
For many people, the perks of employer benefit packages are almost as important as the salary they earn. Medical insurance plans, retirement savings accounts, pensions, life insurance, and disability are just some benefits your employer may offer.
While you may have to opt into some plans and pay premiums, it's usually at a significant discount over what you would pay if you enrolled as an individual.
However, these benefits are subject to federal law and, when something goes wrong, you may need to hire an attorney who's familiar with the Employee Retirement Income Savings Act (ERISA).
How to Find an Attorney Who Takes ERISA Claims
If you submit a claim for long-term disability (LTD) with the company group plan and are denied, you may appeal. However, the process—which is established by ERISA—is complicated, and favors the insurance company that denied your claim.
Because these appeals aren't like other insurance claims, not every attorney is qualified or willing to take them. You want a disability attorney who is:
- Familiar with the law. Appeals of long-term disability claims governed by ERISA follow specific processes, and the time for filing an appeal is limited. An attorney with insight on how appeals work under ERISA can work quickly and efficiently to file a strong appeal.
- Experienced with ERISA claims. The more ERISA appeals an attorney has handled, the better prepared he or she will be to manage your application.
If an attorney doesn't advertise his services as an ERISA attorney, he's probably not well-versed in the process, even if he's willing to take your appeal. Try to find an attorney who wants these claims and will work hard to file a strong appeal.
Monast Law Office Welcomes ERISA Long-Term Disability Appeals
When your employer-sponsored group LTD claim is denied, call my office in Upper Arlington to learn more about my expertise for handling these claims. As a workers’ compensation attorney with over 30 years of experience, I know what it takes to build a strong disability claim, and I understand how the ERISA process works. Time isn't on your side with a denied LTD claim. Contact Monast Law Office to get off to the right start with your appeal.
How do I file a claim for long-term disability?
You’ve had the policy since you started in your current job, but hoped you’d never need it. Unfortunately, an illness or injury has left you unable to work, and you think it’s time to file a claim. By understanding your policy and the application process, you may be able to save yourself time and aggravation.
As a workers’ compensation and long-term disability appeals attorney, I help clients who are struggling to get approved for the benefits they deserve.
What Does Your Policy Cover?
The first thing to do is to read and understand your policy. Each policy defines what the insurance carrier considers a qualifying disability to be, so you'll have to make sure your illness or injury meets those specific standards. Disability under your policy may be defined as a condition that prevents you from performing your current type of work, or it may require you to be unable to perform any work.
Your policy also outlines time limits for applying for benefits and any exclusions, such as pre-existing conditions and specific medical issues that aren't covered. Ensuring that you meet the requirements of your policy before applying can save you a lot of trouble down the road.
Supporting Your Claim With Medical Evidence
Whatever the specifics of your policy might be, the carrier will require you to provide medical evidence to prove you're disabled. This evidence includes records from your treating physician, lab test results, hospital records, and MRIs, or other scans.
Also, ask your doctor for a detailed description of your medical history and the physical limitations you're experiencing because of the illness or injury. The space allotted on the insurance company’s form might not be sufficient to provide these details, so a separate statement may be necessary.
What If You're Denied?
Even if you understand your policy and submit a complete application, you might be denied. In some situations, you may be able to file an appeal, but this is often a complicated process. If you have long-term disability insurance through your employer, the appeal process is probably subject to the rules established by the Employee Retirement Income Savings Act (ERISA). These rules are complicated, and not many attorneys are willing to help with an ERISA appeal.
However, my team at Monast Law does accept these claims and would be happy to take a look at your application to determine if an appeal is an option for you. Contact our office in Upper Arlington to find out if we can help.
Why was my long-term disability claim denied?
You opted into your employer’s long-term disability (LTD) insurance plan thinking it would protect your family if something happened to you that prevented you from working. Now that your fears have come true, you're shocked to discover that your claim for LTD benefits is denied. You’ve paid your premiums reliably for years—how could this happen? We look at common—and often petty—reasons LTD claims are denied.
Insurance Adjusters Are Paid to Deny Claims
The first thing to realize is that insurance companies only make money on the claims they deny, so their adjusters will look for any undotted "i" or uncrossed "t" to throw out your claim. You may not even be given a reason when your claim is rejected, but it's probably for one of these reasons:
- Small print in your policy. You must meet the terms of your specific LTD policy, including its definition of a disability. Most policies exclude pre-existing conditions, so if the claims adjuster believes your condition isn't new, you'll be denied.
- Lack of evidence. You must include evidence of your medical condition and your physical limitations. Medical evidence includes doctors’ reports, scans, and lab tests, which have to be dated within the period of eligibility. Statements and evaluations from doctors and occupational experts attesting to your inability to perform work must also be included.
- Application errors. Incomplete applications, or forms with even minor mistakes on them, will likely be rejected immediately.
- Missed deadlines. You must meet strict deadlines when applying for LTD benefits. If you miss a deadline, your application won't even be read.
- Evidence of duplicity. An approved LTD claim means a hefty payout by the insurance company, so it may go to great lengths to prove your claim is fake. Tactics such as monitoring your social media, spying on you in public, and speaking to friends and co-workers aren't beneath adjusters instructed to find any reason for fault. They won't hesitate to misconstrue perfectly innocent actions as being evidence of fraud.
If you're denied for any of these reasons, or have no idea why your claim was denied, you may be able to file an appeal helped by a long-term disability attorney.
But Not Just Any LTD Attorney
Employer-sponsored long-term disability insurance policies are regulated by the Employee Retirement Income Security Act (ERISA), a set of complicated federal laws originally intended to protect workers’ retirement savings. ERISA now also includes provisions that dictate how LTD claims and appeals should be handled.
Because these cases are complex and time-consuming, few attorneys take them, but I do. As an experienced Columbus workers’ comp attorney, I understand the frustration of a denied LTD benefits claim. Call the Monast Law Office to discuss the possibility of filing an appeal. We'll take a look at your claim and let you know if we can help you navigate the difficult ERISA process.
Am I getting the best care from my workers’ comp doctor?
That’s a great question, and it’s one we encourage our clients to ask. The problem is that some workers’ comp doctors cave to pressure from employers to get people back on the job or to Managed Care Organizations (MCO) to cut costs.
This absolutely should not happen. Your workers’ comp doctor should only be concerned with your well-being. If this isn't the case, it may help to talk to an attorney.
The Physician’s Role in a Workers’ Comp Claim
While you can see any doctor—including your own—for your initial evaluation after a workplace injury, you must choose from a list of BWC-approved physicians after that. These doctors don't work for the BWC, but are approved by the BWC to handle workers’ comp claims.
Doctors who see workers’ comp patients are expected to provide the same medical care as they would to any other patients, such as:
- Recommending treatment, regardless of what the MCO or self-insured employer will voluntarily pay.
- Advising the patient of possible alternative diagnoses, treatment options, and associated risks.
- Evaluating all symptoms, even those that may seem unrelated to the workplace injury.
- Objectively assessing impairment or disability and the employee's readiness to return to work.
- Providing medically-appropriate restrictions when the worker returns to the job.
Potential Conflicts of Interest for Workers’ Comp Doctors
Along with helping the patient get better, the workers’ comp doctor may also be expected to make judgments about the cause of the individual’s injury and his readiness to return to work. This might create a conflict for some doctors when employers pressure them to support a claim denial or to release a patient to work before he's ready. Be especially careful when your employer refers you to a particular medical practice, in-house medical dispensary, or local "work health center" for treatment.
Again, your doctor’s primary job is to care for you, not to worry about your employer. If you feel like your care is compromised because your physician is trying to please your employer or MCO, it may be time to change doctors and talk to an attorney.
Monast Law Office Cares About Your Recovery
The BWC allows you to switch doctors, but you must submit a change form and can have only one physician of record at a time. If you go to a doctor who isn't BWC-certified, you must pay for this care yourself.
If you're having difficulty getting the treatment you need from your workers’ comp doctor, contact my office and talk to my team. To learn more about your right to workers’ compensation, request a free download of our book, The Worker’s Guide to Injury Compensation in Ohio.
If I contract an infectious disease at work, will I be covered by workers’ comp?
People often think of workers’ comp as an insurance program for work-related injuries—which it is—but it also covers illnesses that are contracted due to workplace exposure. Some examples of work-related illness include respiratory conditions, hearing loss, skin diseases, heatstroke, and heavy metal or gas poisoning.
While these diseases result from dangerous conditions in the work environment, an employee may also contract an infectious disease in the course and scope of employment. In some cases, those individuals will also be covered by workers’ compensation.
No Coverage for the Common Cold
Catching an illness like a cold, the flu, chickenpox, or measles from a coworker doesn't qualify for workers’ compensation. You can take sick days and work with your private health insurance regarding payment of medical bills. Even if you catch these airborne diseases from a customer or patient as you're doing your job, you won't be covered by workers’ comp in Ohio.
So What Kinds of Infectious Disease Are Covered?
According to the Ohio Bureau of Workers’ Compensation, private employers are required under the Occupational Safety and Health Administration (OSHA) to pay for all costs related to worker exposure to infectious diseases through contact with blood or other bodily fluids. There doesn't have to be an unavoidable accident or physical injury for this coverage to apply, but it doesn't include airborne exposure.
Public employers aren't subject to OSHA rules, but under Ohio law, they must offer the same coverage for emergency workers, including peace officers, firefighters, and emergency medical personnel. If these workers, or any private employees, come in contact with the bodily fluid of a person infected with a communicable disease, they should be compensated for:
- Office visits
- Emergency room visits
- Tetanus, HIV, or hepatitis testing
- Suturing or dressing of wounds
- Physician evaluation/management, including counseling
- Prophylactic medication
- Follow-up testing/treatment required according to the current Centers for Disease Control protocol.
In order to have these costs covered, it's important that you report the exposure incident as soon as possible. If you were potentially exposed to an infectious disease by a splash or spatter in the eye or mouth, skin puncture, cut, open sore, wound, lesion, abrasion or ulcer, or in the course of performing mouth-to-mouth resuscitation, your medical costs should be compensated.
Call Monast Law Office If You Have Any Problems
These kinds of claims should be straightforward in Ohio, but if you're struggling to get medical testing or prophylactic treatment paid for by your employer, give us a call. To learn more about your right to workers’ compensation, request a free download of our book, The Worker’s Guide to Injury Compensation in Ohio.
Has Amazon improved working conditions in its Ohio fulfillment centers?
It was big news in 2018 when Amazon was named one of the most dangerous places to work in America. Everybody’s favorite click and ship retailer was slammed for pushing hourly workers too hard and creating dangerous work environments for year-round and seasonal employees.
I took a look at the story around Christmastime and reminded readers that even part-time and seasonal employees may have workers’ compensation if they're injured in a fulfillment center.
Unfortunately, little seems to have changed since then, and individuals continue to suffer serious injuries because of the high-pressure environment Amazon has created.
On-Site Clinics Don’t Help
A lot of employers provide on-site health clinics, and Amazon is no exception. The problem with these clinics is the healthcare providers work for the company—not for the patient—and their goal is to patch people up and get them back to work.
In Amazon’s AmCare clinics, they don’t employ doctors. Instead, they hire certified EMTs to provide first aid care, which isn't even legal in some states. Workers report being given ice packs when they visit an AmCare clinic for acute and chronic injuries, but not being given the opportunity to report their injuries. This routine of giving first-aid and returning warehouse employees to the floor is exactly the situation that leads to chronic injuries and ultimately a disability that keeps people off work.
Your Rights as an Amazon Employee
If you work at an Amazon fulfillment center in the Columbus area, you may not have been given information about workers’ compensation, but you're still entitled to it if you're injured on the job and cannot work.
With few exceptions, no matter where you're employed, your medical bills and lost wages are covered by Ohio workers’ compensation when you're hurt at work. Employers who think they are above the law—like Amazon—may violate your rights when you suffer a work-related injury.
Protect Your Rights With Reliable Information
If you want to learn more about Ohio worker’s comp, download a free copy of my book, The Worker’s Guide to Injury Compensation in Ohio. In less than 30 minutes, you'll know how to handle filing a claim, the steps to avoid contested claims, and what to expect if you have pre-existing conditions.
If you have specific questions for me about an injury in an Amazon warehouse—or any other workplace—call me. I’d be happy to help you get the benefits you deserve.
If my employer offers modified work, do I have to take it?
Probably. When you're collecting workers’ comp after a workplace injury, your employer’s goal is to get you back to work as soon as possible.
Depending on your injuries, your treating physician may release you for work with certain restrictions.
If your employer can provide you with work that accommodates those restrictions, you must probably take it. However, you want to make sure it's a valid offer.
What Is Modified or Light Duty Work?
If the doctor says you're able to perform work after a workplace injury, an employer may modify your previous duties or create a new position to accommodate you. The Ohio Bureau of Worker’s Compensation (BWC) encourages employers to offer options such as:
- Transitional work. Some employers offer a program that brings workers with physical restrictions into the workplace to contribute productively under the direction of rehabilitation professionals.
- Job modification. If an employer can remove or alter the physical barriers preventing an injured worker from performing the essential functions of the job, he or she may be brought back to the job before recovering.
- Gradual return. A recovering worker could be asked to return to work on a graduated basis, slowly building up to full-time work over a 13-week period.
It costs companies to have employees off for long periods, so they're motivated to get you back to work, even if you're limited in what you can do. Not every job situation lends itself well to modification, but employers may try anyway and in their rush, cross a line.
What to Watch Out for When Offered Modified Duties
When an employer is worried about the bottom line, they can easily violate your rights as an injured worker. While you have to accept a valid offer of modified work if your treating physician approves, also be aware that:
- You're entitled to wage loss compensation if the modified work you're offered pays less than what you earned before the injury.
- A supervisor may not have the authority to offer modified work. Be sure to understand who's making the offer and confirm that it's a valid offer.
- Workplace health centers, such as OhioHealth’s WorkHealth clinics, have mixed loyalty. They work for your employer, not for you, so they may push you back to the job when you’re not ready.
- Employers can be sneaky. They may promise you modified tasks and then not follow through by honoring your doctor’s restrictions.
When you're injured at work, your employer should treat you with respect and give you the time and space you need to heal completely before returning to full duty.
How an Attorney May Be Able to Help
An Ohio worker’s comp attorney can make sure your rights are protected when you're offered modified or light duty work. It's difficult to advocate for yourself in these situations, but I can make sure you're not being taken advantage of by your employer.
Get more information about workers’ comp in Ohio by requesting a free download of my book, The Worker’s Guide to Injury Compensation in Ohio and then call me to talk about your modified work offer.
How does the BWC decide if my medical expenses will be reimbursed?
Some people—and, unfortunately, many employers—believe that workers’ comp recipients are gaming the system and not doing the things they need to do to get better and return to work.
However, I've found over many years of practicing workers’ comp law that my clients want nothing more than to recover and get back to the work that made them feel like contributing members of society. My clients often push for newer, better, or alternative treatments to help them heal more quickly.
The problem isn't about getting better. The problem is often gaining approval for the treatment that will help them do just that.
MCOs Must Apply the Miller Criteria to Requested Treatments
As with everything related to Ohio workers' comp, getting approval for a medical procedure, service, or treatment is a process. When you or your doctor request approval from your Managed Care Organization (MCO) for a new treatment, the state Bureau of Workers’ Compensation (BWC) requires that a three-pronged test, referred to as the Miller Criteria, be applied.
The medical service you're requesting has to meet all three of these criteria:
- It must be reasonably related to the industrial injury.
- It must be reasonably necessary and appropriate to treat the industrial injury or allowed condition.
- The costs of the services must be medically reasonable.
The MCO may consult the Official Disability Guidelines when deciding, but ultimately, the choice is up to its judgment.
Miller v. Industrial Commission Ruling
The Miller Criteria arose from a 1994 Ohio Supreme Court ruling on a case involving an injured woman who was obese. Even though her weight wasn't a factor in her workplace injury, her doctor believed it was preventing her from recovering, so he recommended that she enter a supervised weight-loss program.
Her employer’s MCO denied coverage of the program, and she appealed to the Supreme Court. The Supreme Court drafted these criteria and ruled that they must be applied to her request for medical service. Her weight loss treatment was approved, with the requirement that the weight loss would help her overcome her injury and not just ease her discomfort—standards now routinely applied to weight-loss programs paid for by workers’ comp.
The Miller Criteria were later embedded in Ohio workers’ comp law and are now applied to every treatment request, not just weight loss.
Do the Miller Criteria Sound Vague and Subjective to You?
That’s because they are. If you're facing a denial of treatment, an experienced workers’ comp attorney might have to argue for the validity of the treatment your doctor says you need.
Learn more by requesting my free guide, Worker’s Guide to Injury Compensation in Ohio. Then call my office to schedule a meeting to discuss your specific situation.
What can I do if my employer claims I voluntarily abandoned my job?
If your employer raises a voluntary abandonment defense to deny your application for permanent total disability (PTD) or temporary total disability (TTD) under Ohio’s workers’ compensation program, he may have opened a can of worms that could turn into a long legal battle.
If you're facing this defense, run—don’t walk—to a workers’ comp attorney. As I've discussed in an earlier blog, the voluntary abandonment defense is based on court decisions, not a statute or rule, so it’s anyone’s guess on how a hearing officer will decide.
What Is Voluntary Abandonment?
Although voluntary abandonment defenses are never simple, the idea behind them is relatively straightforward.
If you're collecting PTD or TTD or applying for these benefits, and you retire, get fired for breaking a rule, or quit working altogether; your employer or the Bureau of Worker’s Compensation can claim you voluntarily abandoned your employment and are therefore ineligible for benefits.
Once the company makes a claim, it's up to the hearing officer to determine if you have voluntarily abandoned your job. Past rulings have been inconsistent, with some judges interpreting the defense much more strictly than others.
Ohio Industrial Commission Amends Its Information
- In April 2019, the Ohio Industrial Commission (BWC) amended the section on voluntary abandonment in its manual on adjudications—apparently to clarify past rulings. While not introducing any new guidelines, the memo defines three types of actions that could be considered voluntary abandonment:
- Voluntary retirement. When a worker retires for reasons unrelated to the injury or illness he or she suffered at work, this can give rise to a finding of voluntary abandonment.
- Termination. If someone is fired for breaking a written rule or condition of employment he or she should know, there could be cause for voluntary abandonment.
- Abandonment of the workforce. If a worker is capable of performing light-duty or modified work but fails to return to the workforce, it may be considered abandonment.
Cases are decided individually. Evidence can be presented on your behalf to counter the affirmative defense, but you'll need help to build a persuasive argument.
Consult an Ohio Worker’s Comp Attorney
A voluntary abandonment defense might create a difficult battle for you. If your employer or the BWC raise this as a defense in your claim, you must consult an attorney to protect yourself. To learn more, request a free download of my book, The Worker’s Guide to Injury Compensation in Ohio, and call me to discuss your situation.
Free Consultation—What’s it mean?
Lawyers are just like anyone else – we have only so much time in a day. Some lawyers charge by the hour while others charge a flat fee for a service. Other lawyers charge a contingent fee, which means they get paid only if they win your case. When the case is won, they take a percentage of the money they earn on your behalf.
When a lawyer says that he or she will provide a free consultation, it means they will sit down with you, hear about your problem, and give you initial thoughts about it, at no charge or obligation to you. This meeting gives you a chance to "interview" the lawyer and the lawyer to interview you. After the meeting, you may decide that you do not want to hire the lawyer and, likewise, the lawyer may decide that he or she cannot help you with your problem.
During our visit, you can ask about our experience with matters similar to yours, our thoughts on the best course of action for your situation, and the timeline for a case like yours. You will also get to meet the people assigned to your case if we represent you.
The discussion should help you discover your rights and whether you need an attorney to represent you. Sometimes, the consultation itself may provide you with enough information to solve your workers’ compensation issue.
The meeting usually lasts somewhere between 15 and 30 minutes and can be done in person or over the phone—sometimes both. We will discuss the facts of your case, review the legal and practical issues you may expect to face and outline how we might pursue your case if we work together. If your claim is more complicated, the consultation can take a little longer. We want to take the time to understand your situation.
Preparing for Your Free Consultation
The more prepared you are, the less time it will take for us to understand and discuss your legal issue with some level of intelligence. Look through my website for answers to lots of questions you may have and download a copy of my book The Worker’s Guide to Injury Compensation in Ohio. It’s free, jam-packed with thrilling information about Ohio workers’ compensation and more fun to read than just about anything you can imagine! (OK, even I have to give that statement a few Pinocchios). Also, if we meet in person,
- Bring all documents. Make copies of all the materials you have collected regarding your case. Give these copies to the lawyer.
- Get organized and take notes. Write down notes outlining your legal problem, or questions you may have. We need details to decide what is essential and how to move forward in your best interests.
- Be honest. You should give an accurate account of your legal problem. This includes issues that may be sensitive to you or your family. Remember that the conversation with us is private, and cannot be discussed with others without your permission.
- Talk about how much this will cost you. We strictly work on a contingency fee basis for our workers’ compensation clients.
- Ask questions. For us to serve you better, I want you to understand your case and the legal procedure. My job is to guide you through this process that can be lengthy and frustrating. It's no help to either of us if we don’t have clear communication. I’d prefer you ask questions than not.
- Read all documents carefully before signing. Before you sign a document, we will explain to you what exactly it is that you are signing. If you do not understand the material you are being asked to sign, ask us to go over it again.
- Keep your own files. We’ll do our best to copy you on all letters and documents prepared on your case. Also, keep the written fee agreement between you and your lawyer for your records.
- Listen! My evaluation of your situation is based on legal training and experience. Remember that I cannot work magic. No lawyer wins every case, and sometimes the best legal advice may not be what you want to hear. I will advise with your best interests in mind.
A free consultation with us is easy to set up by calling 614-334-4649.
- Bring all documents. Make copies of all the materials you have collected regarding your case. Give these copies to the lawyer.