Types of Claims

TYPES OF CLAIMS
There are two types of Workers’ Compensation claims – (1) those called medical only claims, which means that only medical expenses are paid; and, (2) those called time loss claims, which means medical expenses and temporary compensation benefits for lost wages are paid. A detailed explanation of both types of claims follows:


Medical Only Claims

Medical only claims are those types of claims for which the insurance company will pay all of the medical expenses associated with your injury, but will not pay compensation benefits for lost wages because you did not lose more than 7 days time from work. Examples of medical expenses that are paid are emergency room charges, doctor’s fees, prescriptions, crutches, braces and splints. If you have personally paid for medical expenses related to your injury, send your receipts to the insurance company for reimbursement.

On medical only claims, the insurance company does not have to let you know that they are accepting the claim and you can assume all medical bills will be paid. Even though you do not lose time from work, you will continue to have your medical bills paid until the doctor states you have recovered and do not need further treatment. If you stop treatment because you believe you have recovered, the carrier may close your claim without the doctor’s discharge.

Once your claim is accepted, you are not responsible for the payment of any medical expenses for treatment related to your injury. If you receive a bill and are being asked to pay it, call your insurance company to find out why they have not paid it.

While you are under active medical care, it is important for you to remember that the insurance company has the right to have you periodically examined, at a reasonably convenient time and place, by a doctor of its choosing. Failure to attend the examination could result in suspension of your benefits, and you could be required to pay for the cost of the missed examination. The insurance company may accept the opinion of its consulting doctor and base a change in your claim status, or the closure of your claim, on that doctor’s opinion.


Time Lost Claims
If a doctor states you are unable to work because of your injury and you are off work more than 7 days, you are entitled to compensation for your lost wages. The days off do not have to be consecutive (in a row) but are cumulative (total). Entitlement to compensation is based on calendar days (not work days) and includes Saturdays, Sundays and holidays.

The first 7 days off are not paid for lost wages unless your disability extends to 14 days. For example: If you are off 10 days, you get paid for days 8, 9 and 10 only. If you are off 14 full days, compensation is retroactive (goes back) to the date of injury and you are paid for 14 days. Compensation is not generally paid for the date of injury because you were working that day. Compensation is paid at 66-2/3% of your average monthly wage. The average monthly wage is usually calculated on your earnings during the 30 days before your injury, although there are other methods for calculating the average monthly wage. The law establishes a maximum wage figure which can be used to calculate the average monthly wage. As of January 01, 2009, the maximum 4 monthly wage is $3,600.00. Even though you earned more than $3,600.00 per month, the most a person can receive is 66-2/3% of $3,600.00. The wage is set as of the date of injury. The law does not allow for cost of living increases.

If you are losing time from work, the law requires that the insurance company inform you that your claim is being accepted by sending to you a Notice of Claim Status form with your first temporary compensation check. The Notice will tell you the wage as calculated by the insurance company. A second form, Wage Calculation Sheet, should be attached to the Notice. This form will explain how the insurance company arrived at the figures. The same information is also sent to the Industrial Commission for review.

The ICA reviews the insurance company’s calculations and issues the Notice of Average Monthly Wage which officially sets the wage. If the wage is not calculated correctly, the ICA can disapprove the wage and establish the correct wage. Because the ICA’s review covers only the reasonableness of the data and the accuracy of the calculations, it will send you a letter seeking your assistance in verifying the accuracy of the figures used in the calculations. If there is a question regarding the accuracy of the data used in calculating the average monthly wage, you are asked to contact the Wage Section of the Industrial Commission’s Claim Division.

Remember, you only have 90 days from the issuance date of this Notice to protest the accuracy of the Average Monthly Wage. After that period, the Notice becomes final and can only be appealed under very restricted circumstances. Again, to avoid any delay or loss of benefits, make sure that the insurance company and the Industrial Commission have your current address.

For more specific information regarding your Phoenix workers compensation claim contact Chris T. Johnson a Phoenix Workers Compensation lawyer.

Call: (602) 254-6461