How Workers' Compensation Settlements Work Part One: Denied Claims

Settling Your Denied Claim

Oregon Workers' Compensation allows you to settle your claim, even if it has been denied.  This kind of settlement is called a "Disputed Claims Settlement."  You should be careful about signing these agreements, because in many cases, injured workers may not be aware of what issues they are really settling, what benefits they are giving up, and the value of those benefits.

Denied Claims

Disputed Settlement Agreements are also referred to as "DCS's."  When you enter into a DCS, you are agreeing to walk away from the claims denial in exchange for money. Injured workers and insurance companies often agree to a DCS after a claim denial is appealed, but before a hearing.  Once the agreement is approved, you are no longer able to go back to the Workers' Compensation Board and seek further relief on this denied claim.  Here are few questions you should ask yourself when thinking about a DCS.

Are There Outstanding Medical Bills?

If there are outstanding medical bills, and the insurance company has those bills in its file, the insurance company will pay at least a portion of the bills out of the settlement.  Certain rules limit what percentage of the overall settlement can go toward paying medical bills. You may still be responsible for medical bills, even if some have been paid out of the settlement. You should not settle your case until you have a clear understanding of how the bills are going to be paid.

What About Future Medical Care?

Another important factor to consider is the need for future medical care. If you have health insurance, then most health plans will not cover medical care from an on the job injury.  However, many health plans will pay the medical bills while you are fighting the denial, but only if you agree to pay back the health plan the bills it paid for health care if you settle the case.  Even if you have that kind of agreement with the health plan, you should know how your health plan will treat future medical care.  Of course, not having health coverage is a whole different issue when deciding whether to resolve your claim with a DCS.

How Strong is Your Case?

You should also consider the strength of the claim. Many claims are denied because of a medical opinion.  If all the doctors involved in your claim, including the IME doctors, agree that your medical problems are from the on the job injury, then you may have a very good chance of winning your appeal.  That will affect the claim's value, but it has to make you wonder if settling is the right move.  Asking the insurance company to retract the denial and process the claim may be a better option. But, if the doctors do not agree about whether your medical problems are from the on the job injury, your chances of winning the appeal are an open question, and a DCS may be a better option.

What is Being Denied?

Often times, a claim is denied generally, which means that the insurance company disputes that the on the job injury did not require any medical care or disable you from work.  What kind of injury you suffered does not matter.  Other denials are in response to your request to accept a certain medical condition, which is a new medical condition claim.  Regardless of how you got to this point, insurance companies often include a laundry list of medical conditions in the DCS agreement, which effectively denies all the listed medical conditions. This is a big deal because these settlements, at least in theory, should be based on the value of the benefits you are giving up.  The type of injury you suffered, how well the doctors can treat it, and whether you can recover enough to go back to work affect the insurance company's cost of processing your claim.  You need to know what you are selling to this insurance company.

What is Your Plan?

Sometimes the numbers that are thrown around when resolving these cases are pretty significant, but in the long term, they are not.  You may have resolved your case for a pretty decent amount, but after the money runs out, then what?  If you are not able to go back to your job, what are your options.  Does the employer have to take you back anyway?  Can you get job training elsewhere?  These are just a few of the questions you have to grapple with, especially with a life changing kind of injury.

What about a Claims Disposition Agreement?

The insurance company may have approached you about this kind of settlement.  Claims Disposition Agreements are settlements of accepted claims.  To learn more about these kinds of agreements, read Part II of this article.

The Bottom Line

The bottom line is that if you are thinking about a DCS, you have to know what it is your selling to the insurance company, and what it is worth.  Sometimes, a DCS is a great tool for the injured worker, and other times, not.  We review claims files and work with injured workers all the time to help them decide whether they should settle the case, or forge ahead.  Any questions?  Call us at 503-325-8600.   When we help injured workers in Oregon, there is no fee unless we obtain a positive result for you.