If you’ve been hurt at work, you might assume the workers’ compensation system is there to help you. But the reality is that insurance companies often use a variety of tactics to protect their bottom line, and knowing what to watch out for can make a big difference in your case.
Insurance companies sometimes hire private investigators to keep an eye on injured workers after a claim is filed. These investigators may follow you during everyday activities, like going to the grocery store, running errands, or attending doctor’s appointments. They may record video of what you’re doing in hopes of catching something they can use to challenge your injury.
They may also learn details like what car you drive, where you live, and when you’re scheduled for medical exams. In some situations, investigators even approach injured workers under false pretenses, pretending to be someone who needs help or wants to look at a rental, just to see if you’ll perform a physical task they can later use against you.
Medical treatment is one of the most important parts of a workers’ compensation case, and insurance companies know it. One way they push back is by sending injured workers to what’s called an Independent Medical Examination, or IME. Even though it sounds neutral, the doctor performing the exam is hired by the insurance company and may give an opinion that downplays your injury, disagrees with your treating doctor, or says certain treatment is unnecessary.
Insurance companies may also require you to sign HIPAA medical release forms that give them access to your medical history. Once they have those records, they may go digging through years of past medical information looking for any prior injury or complaint they can point to. If they find something, they may argue that your current condition is related to that older issue instead of your workplace accident, which can reduce the benefits they have to pay.
Delays are another tactic that can show up in workers’ compensation cases. When your doctor requests treatment, like surgery, the insurance company usually has a set amount of time to respond. In many situations, they’ll use every bit of that time before approving or denying the request, which can leave injured workers waiting while they’re in pain and unsure about what happens next.
Sometimes treatment requests get rejected over small technical issues, like a missing checkbox or a form that wasn’t submitted exactly the way the insurance company wants it. When that happens, the request often has to be resubmitted, which can add weeks or even months to the process. In other cases, insurers may say they’ll approve treatment “without prejudice,” which can create problems because doctors and hospitals may hesitate to move forward if there’s any doubt about whether the insurance company will actually pay.
In workers’ compensation cases, your benefits are largely based on something called your Average Weekly Wage, which reflects what you were earning before the injury. Insurance companies rely on your employer to report that information, and sometimes important parts of a worker’s pay can be left out.
For example, overtime, bonuses, housing benefits, utilities, or other forms of compensation may not get included when your wages are reported. In some cases, income from a second job may also be ignored. If those earnings aren’t counted, your Average Weekly Wage ends up lower than it should be, which means your weekly benefits are lower too.
That’s why it’s important to keep records like pay stubs, tax returns, and any proof of income you have. Those documents can help make sure your compensation rate is calculated correctly and that you’re not missing out on benefits you’re entitled to.
If you’ve been hurt at work and you’re not sure what your next step should be, feel free to give me, Rex Zachofsky, a call. I’m always happy to talk through your situation, answer your questions, and help you understand what your options might be.
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