Workers’ Compensation is a “no-fault” system. Does a “no-fault” system mean you have nothing to prove? No. Quite to the contrary. The self-proclaimed “self-executing” Florida Workers’ Compensation Law is designed to give you a lot to prove in order to receive medical and/or disability benefits. The is nothing “self-executing” about it.
When does a workers’ comp claim get denied?
Denying the Entire Claim: Workers’ compensation carriers scrutinize every claim, looking for ways to deny claims and benefits. The first thing they do is evaluate the “compensability” of your claim, which means they look for ways to challenge your right to bring a claim in the first place. The first questions are: did your injury arise out of and occur in the course and scope of your employment. There is an entire body of case law evaluates and defines what this means. The insurance company has experienced defense attorneys who look at claims and advise them on whether they can deny the compensability of a claim, which is to say, they try to look for ways to deny your entire claim. Even if they initially accept your claim as “compensable” and provide you with benefits, this scrutiny can and will continue. While Florida Law generally requires them to make a denial of compensability within 120 days of the first provision of benefits, if they can find a way to deny your claim in the future, they will.
Denying Benefits: even when the insurance company accepts your claim as compensable, you are not guaranteed to get the benefits you should. They will look at every benefit you seek, both medical and disability, and look for ways to deny that benefit. This will go on as long as you are in the work comp system.
The moment in your claim when hiring a lawyer actually matters
Many injured workers start their cases off thinking that their employer and their workers’ compensation insurance company are on their side. While there are some rare cases where an employer truly cares about their employee, the vast majority of employers want you either back to work or gone so they can replace you. Some employers will even fire you for making a workers’ compensation claim, which is a violation of the Florida Workers’ Compensation Law. Regardless of how your employer views you, they have little control over your claim. The insurance company has virtually all the power and control, and they are definitely not on your side.
So, when do you need a workers’ compensation lawyer? The only time you may not need one is for minor accidents that result in no or very little lost time from work, no permanent injury, and no prolonged treatment – meaning you get back to work immediately and truly do not need to go to the doctor again. If you have a serious injury that requires seeing a specialist, then having a lawyer from the beginning can protect you from making missteps and also allow a lawyer to act much more quickly to protect your rights. If you wait to hire a lawyer until you have a problem in your case, it will take that lawyer longer to act than if they were already representing you, and you’ll never know if having that lawyer could have helped you avoid the problem in the first place. So, the best time to hire a lawyer is the moment you realize that you have an injury that is not going to go away quickly.
Red flags your adjuster is about to screw you
They want a recorded statement. The are not entitled to a recorded statement, but they won’t tell you that. They will just say the need to take your statement. When you give a recorded statement in a Florida Workers’ Compensation case, you are giving the adjuster access to personal details about your life that they would not otherwise get. What purpose could they possibly have for taking your statement? Only one: to find a way to deny your claim or deny your benefits. There is literally no other legitimate purpose.
They want to send you to a “second opinion” or an Independent Medical Examination (IME). They are not entitled to a second opinion (and neither are you), so if they say they want you to go see another orthopedic doctor for a “second opinion” that means they don’t like what your authorized treating physician is doing. If they schedule an IME, that is a huge sign they are looking to deauthorize your current doctor or deny recommended treatment. There’s only one thing they don’t like: spending money. So, when your authorized treating physician recommends treatment or takes you off work, that costs the insurance company money. They will immediately start looking for ways to not authorize the care or pay the disability benefits.
They send a Nurse Case Manager to meet with your doctor or attend your appointments. Nurse Case Managers say they are there to facilitate care. While that can be true in some cases, most of the time they are there to do two things: pressure you doctor to release you back to work and make sure they doctor knows you have pre-existing conditions, if you do. Neither one of these things helps you. If your doctor isn’t ready to release you back to work, they shouldn’t. Unfortunately, many times doctors cave in. They get tired of having the case managers bugging them, and the quickest way to get rid of them is to simply agree to do what they are suggesting.
They hire a defense attorney before you hire your own attorney. There is only one reason for them to hire an attorney if you don’t have one: to prepare to deny your case. If you get correspondence or a phone call from an attorney representing the insurance company, run! Don’t talk to them. You should absolutely find an experienced workers’ compensation lawyer to help you.
How a lawyer changes the settlement value
Settlement is always voluntary in Florida Workers’ Compensation cases, which means you can’t make the insurance company pay you a settlement and they can’t make you accept a settlement. Having said that, they always want to settle. There is simply a limit to the amount they will pay. Having a lawyer in your corner does two things to increase the settlement value of your claim. First, you will get a good evaluation of what your case is worth and what the carrier should pay. Second, a lawyer will press them to pay benefits which costs them money. When they are not spending a lot of money on your case, they have little incentive to pay you a big settlement. By forcing them to pay for the benefits they should be paying, they are going to value your case higher because you are costing them more money. It’s that simple. If you don’t have a lawyer, you don’t have a real threat to make them pay what they should.
In short, if you are going to be in the workers’ compensation system for any real period of time, you should hire an experienced workers’ compensation lawyer; someone who knows the law and the system; someone you can trust to guide you and protect your rights. Florida Workers’ Compensation lawyers who represent injured workers, like all injury lawyers, work on a contingent fee, which means you don’t have to pay anything up front. So why not hire one? If your case drags on at all, you will be glad you did.
