The Starting Point
The insurance company's investigation of a workers' compensation claim begins when it receives notice of the claim from the injured worker's employer. This starts a sixty-day clock in which the insurance company must investigate and decide whether to accept the claim. This two month period is referred to as the "deferred status" period.
Keep in mind that the insurer may not use all of these investigation tools. Here is what may be in store while you go through the deferred status period.
The Oregon Workers' Compensation statute allows the insurer to take your statement. You are required to cooperate in giving a statement. If you do not, you could be fined. The good news is that recent changes in the law allow you to have an attorney present during the statement, and the insurance company has to pay the attorney's fee. Assume that the insurance company has already investigated the claim, and investigated you. Here are some tips on how to get through a statement.
Reviewing Medical Records
When you filed your claim, you filled out an 801 form. This form is a medical release that allows the insurer to request not only your accident related medical records, but medical records for past treatment. Insurance companies routinely ask for past medical records because they may try to claim your need for medical care is due more to a pre-existing condition than the actual on the job injury.
Talking to Others
The insurance company will often have an investigator question your supervisor, co-workers, and sometimes, your friends and neighbors. If a claim is denied, you are entitled to a copy of the investigation report, which will list all the witnesses contacted, and a summary of their statements. There are exceptions if the insurance company claims that the information is inconsistent with what you told them, or a doctor. That information may be kept from you, and used at a hearing to argue to the Judge that you are not being truthful.
"IME" stands for "independent medical examination." There is often nothing independent about this examination. However, if the insurance company follows the rules, it can require you to attend the examination. The examining doctor has access to your medical records, and possibly other information from your file. The exam itself is often an afterthought, and the report is may be almost completed before you show up for the examination. Here are some tips on how to successfully complete your independent medical examination.
This happens rarely, but it does happen. Insurance companies are often suspicious of a worker's claim, and they may hire an investigator to follow you around, and video tape your activities. The goal here is to see if you are as limited as you say you are. Some people get caught cheating the system, but for every one of those, there are so many more people with legitimate claims, and that is not the video tape you will see on a "caught on video" reality show.
The Final Decision
Your claim will be accepted, or it will be denied. If the insurance company fails to respond within the required time limit, you can request a hearing, and argue that the claim was in fact denied. We lawyers call this a "de facto" denial. You can appeal your denial by filing a request for hearing, and you can retain an attorney to help you with the claim. The lawyer is paid only if he or she wins the hearing, or is able to resolve the claim by settlement. If the lawyer is not successful, there is no fee. Any fee has to be approved by the State of Oregon.
If your claim is accepted, then the insurance company issues a Notice of Acceptance. You should make sure that the insurance company is accepting responsibility for all your medical conditions.
If you have a denied claim, and want to know your options, contact us. If your claim is accepted, and you need to make sure the insurance company has taken full responsibility for your claim, contact us. We can review your file and let you know where you stand.