Answers to Workers’ Compensation Questions From a Columbus Attorney
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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.
As a teacher’s aide, can I get workers’ comp if I'm injured at school?
Teachers’ aides are some of the hardest-working employees in a school. Sometimes called para-professionals or para-pros, these helpers assist certain students and help with controlling chaos in the classroom.
Because of the hands-on nature of their work, they're also prone to be injured on the job. It’s important for these valuable school employees to understand that they can file for workers’ compensation if they're hurt at work, even if they're part-timers.
How Aides Get Hurt at School
If an aide is assigned to work with a student who's health impaired, their job will be physically demanding. Working with students with cognitive or behavioral challenges, as my daughter-in-law does, could mean they're at risk of being assaulted. Teachers’ aides are in the trenches with students, so to speak, and they suffer injuries as often as, or even more frequently than, classroom teachers.
Some causes of para-pro injuries include:
- Outbursts and attacks. When an aide is assigned to work with an individual student, they could bear the brunt when the student lashes out or has a tantrum. Being hit, knocked down, or shoved against a wall can cause serious injuries.
- Playground incidents. Teachers’ aides often serve as playground monitors and are the first on the scene if there's a fight. They can also suffer trip and fall injuries, be hit by playground equipment, or sustain a strain or sprain injury while playing with children.
- Handling wheelchairs. Pushing a student in a wheelchair, moving an empty wheelchair, and lifting a student in an out of the chair can all take their toll on a teacher who must do these tasks all day, every day.
- Lifting and restraining. Teachers’ aides are often responsible for physically restraining students having a meltdown and may have to lift and carry the child away to protect other students. These are physically-demanding tasks.
If you get to where the physical demands of your job as a teachers’ aide cause injuries that prevent you from working, you can qualify for workers’ compensation to pay for your medical bills and lost wages, even if you only work part-time. Learn more about your rights as a worker in Ohio by downloading my free book, The Worker’s Guide to Injury Compensation in Ohio.
If you have questions after an injury at school, call my office to speak to one of my knowledgeable team members.
Why was my short-term disability claim denied?
You opted into short-term disability insurance because you were worried about how bills would get paid if you could not work for several months. You thought you were doing the responsible thing to protect your family if an illness or injury prevented you from earning a paycheck. However, when the worst happened, and you had to make a claim, you were denied. How can this be?
It’s All in the Fine Print
Employers in Ohio aren't required to offer short-term disability policies to their employees, but some do. With this coverage, people unable to work for several weeks or months due to a non-work-related injury or illness can file a claim to recover some lost income and additional compensation while temporarily disabled. The conditions covered and the time you're insured depend on the terms of your specific policy.
Some short-term disability policies offer as little as 30 days, while others cover you for a year. However, no policy covers illness or injury caused by your job, because those circumstances fall under the umbrella of workers’ compensation.
Why Was Your Claim Denied?
Short-term disability claims are usually denied for one of these reasons:
- The condition isn't covered. You have to understand the terms of your policy before you apply for benefits. Some policies cover time off for childbirth by C-section, for example, and others don't.
- You didn't provide adequate medical evidence. Even though your disability is only expected to be temporary, you still have to provide medical proof that you're unable to work. If the insurer doesn't think the evidence is sufficient, it will deny the claim.
- The insurer thinks you're lying. Insurance adjusters check out your social media, follow you around, and even talk to your friends and coworkers to find a reason to deny your claim. If they think your behavior contradicts your application for disability, they could deny it.
If you paid your premiums and are legitimately disabled, get the insurance benefits you deserve. If you're denied, you can file an appeal, but need the help of an attorney who handles these kinds of cases. Employer-sponsored benefits are governed by the Employee Retirement Income Security Act (ERISA) and are subject to strict regulations.
Contact Monast Law Office With Your ERISA Claim
As a dedicated workers' comp attorney for over 30 years, I'm honored to provide winning strategies for clients denied an employee benefit covered by ERISA, including short-term disability. Contact our office in Columbus to discover if we can help. To learn more about ERISA and the appeals process, request a free download of our book, Don’t Go It Alone: How Insurance Companies Sabotage Disability Claims.
What changes are coming in 2020 to workers’ comp law in Ohio?
Ohio House Bill 81 (HB 81) was signed into law by Governor DeWine on June 16, 2020. What started as an initiative to expand workers’ comp coverage for post-exposure testing of safety officers will now address several other key issues when it goes into effect later this year.
While the changes might just be legalese to a layperson, they represent significant changes to workers’ comp attorneys like me.
Ohio Workers' Comp Changes Effective September 15, 2020
While testing of peace officers, firefighters, emergency medical workers, and corrections officers exposed to blood and bodily fluids on the job is already covered by workers’ comp, HB 81 expands that coverage. Beginning September 15, 2020, workers' comp extends to employees of detention centers and includes exposure to drugs or other chemical substances. Also, these changes will be implemented when the law goes into effect:
- The voluntary abandonment doctrine regarding temporary total disability claims—which had been based on 25 years of case law—will now be subject to new, specific standards.
- The statute of limitations for reporting violations of specific safety standards will change from two years to one year from the date of injury.
- Funeral benefit cap increases from $5,000 to $7,500 but isn't retroactive.
- Employers can no longer withdraw from a proposed settlement agreement when the claim exceeds their premium calculation, and the employee in the claim no longer works for them.
- HB 81 changes the date that the Industrial Commission can invoke continuing jurisdiction to the time of medical services, rather than the date of payment.
- Expands the time you have to appeal an Industrial Commission decision from 60 to 150 days in specific circumstances for claims pending on and arising after September 29, 2017.
Fortunately, don't worry about how these changes affect your workers’ comp claim because, if you're already a client, my team is taking care of everything.
If you need to file a claim or are struggling with an existing application, please call my office to discover how we may help. At Monast Law Office, we stay informed of changes affecting the Bureau of Workers’ Compensation, the Ohio Industrial Commission, and your claim.
How long do I have to file an appeal of my LTD denial, considering the restrictions imposed under the COVID-19 pandemic?
In March 2020, the world as we knew it changed almost overnight. Most of us were told to shelter in place, work from home, and only go out for essential purposes. Many businesses came to a standstill, at least while everyone adjusted to the changes, and any medical, legal, and government problems not related to COVID-19 were pushed aside or put on hold.
Were you facing a denial of your long-term or short-term disability benefits as this went down, you're probably wondering when you'll be able to continue pursuing an appeal.
Among all the bad news around us these days, one bright spot is that the U.S. Departments of Labor and Treasury unprecedentedly decided to loosen some of the restrictions imposed by the Employee Retirement Income Security Act (ERISA).
What Does This Mean for Your ERISA Appeal?
While ERISA gives you the right to appeal denials of your employer-sponsored long-term disability (LTD) insurance, it does so with fairly rigid restrictions, including a short, 180-day time limit from the date of denial. If you received a denial in the last six months, you were probably just figuring out what to do about it when COVID-19 hit.
Whether you were affected by the pandemic and let the claim slip your mind, or you've been unable to get help because of the restrictions, you might be panicking that your time is running out. To file an appeal, you must see your health providers to get medical reports. If you've been unable to leave your home or your doctors’ offices were closed, you haven't been able to get the evidence you need to support your appeal.
However, given the National State of Emergency issued on March 13, the 180-day time limit has been lifted. On May 4, the following rule change was announced:
“All group health plans, disability and other employee welfare benefit plans, and employee pension benefit plans subject to ERISA…must disregard the period from March 1, 2020, until sixty (60) days after the announced end of the National Emergency or such other date announced by the Agencies in a future notification.”
As of June 1, the National State of Emergency had still not been lifted, so this means that the period from March 1 to an indefinite date cannot be counted against the 180-day time limit for your LTD appeal.
Monast Law Office Is Open for Business and Ready to Discuss Your LTD Appeal
Appealing an LTD denial is difficult in the best of times, and it's especially difficult now. As a board-certified workers’ comp attorney for over 30 years, I'm dedicated to providing people the guidance and representation they need to get the long-term disability benefits they deserve. Contact our office in Columbus to discover how we can help! To learn more about ERISA and the appeals process, request a free download of our book, Don’t Go It Alone: How Insurance Companies Sabotage Disability Claims.