Timeline for the average worker’s comp claim

General Outline/Timeline for an Average Workers’ Compensation Claim

I am frequently asked to provide a general outline/timeline for an average workers’ compensation claim. I hope this is helpful:

1. Get Injured
2. Report Injury to Employer
3. Employer Provides List of Physicians
   • The employer is required to provide a list of physicians.
4. Visit the Occupational Medicine Physician
   • This physician will:
     • Assess your condition.
     • Make recommendations for diagnostics, referrals to specialists (if necessary), and treatment.
     • Provide any necessary work restrictions.
     • Likely provide an opinion on whether the injury is consistent with how it was alleged to have occurred.
5. Insurance Company Admits or Denies Liability for Lost-Time Claims
   • If denied:
     • The insurer files a Notice of Contest.
     • The injured worker must request a hearing and has the burden of proof.
   • If admitted:
     • The insurer files a General Admission of Liability.
     • Temporary disability benefits are paid if work restrictions cannot be accommodated by the employer.
6. Injured Worker Receives Medical Care
   • Subject to approval by the insurer.
   • Continues until Maximum Medical Improvement (MMI) is reached (meaning you are as good as you are going to get).
7. Occupational Medicine Doctor Assigns Impairment Rating
   • In most cases, the doctor will:
     • Give an impairment rating.
     • State whether maintenance medical care is recommended.
   • If the insurer accepts the rating:
     • Benefits are awarded for permanent impairment, disfigurement, and maintenance medical care (if recommended).
     • The insurer files a Final Admission of Liability.
   • If the insurer disputes the rating:
     • They request a Division Independent Medical Exam (DIME).
8. Injured Worker’s Options After Impairment Rating
   • If the injured worker accepts the rating:
     • No action is required.
     • The insurance company will send checks for permanent impairment.
   • If the injured worker disagrees with MMI status or rating:
     • They MUST object to the Final Admission of Liability and request a DIME within 30 days of the Final Admission of Liability.
9. DIME Process
   • If a DIME is requested by either party, the Division of Workers’ Compensation will:
     • Issue a panel of three physicians.
     • Each party strikes one physician.
     • The remaining physician performs the DIME.
   • Importance: Knowing the doctors makes a huge difference.
   • The DIME physician’s opinions on MMI and permanent impairment are subject to a higher burden of proof.
10. If the DIME Physician Determines the Worker is Not at MMI
    • Further treatment is recommended and completed until the injured worker reaches MMI.
11. Post-MMI: Maintenance Medical Care
    • Following resolution of disputes regarding MMI and impairment, the injured worker proceeds with maintenance medical care (e.g., ongoing prescriptions).
12. Right to Reopen the Case
    • The injured worker retains the right to reopen the case if the condition worsens within:
      • 6 years from the date of injury,
      • 2 years from the last date temporary or permanent impairment benefits were payable, or
      • 2 years from the last date medical benefits were payable.
13. Settlement
    • Can happen at any time.
    • Typically prompted by a dispute (e.g., claim denial, denied authorization for surgery, disagreement about MMI/permanent impairment).

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Disclaimer

This is a high-level, generic timeline and not legal advice for any specific situation or question. The Workers’ Compensation Act and Rules of Procedure contain caveats and nuances that could provide exceptions to the timeline above.

📧 Email: brett@walshadamslaw.com
📞 Call: (970) 506-3892 for questions regarding your specific situation.