Yearly Archives: 2015

The adjuster is here to help me, right?

Workers' Compensation

Absolutely not. The adjuster has only one job: to make her company profitable. The way she does that is by limiting how much she spends on your case. This doesn’t mean she’s going to be hateful and evil to you. That rarely works – although they do it sometimes. Rather, she’ll likely be pleasant but doesn’t follow through with things that cost her company money. Things like mileage reimbursements prompt scheduling of medical appointments, and ensuring that you’re weekly checks included credits for overtime, bonuses, and per diems.

What about the adjuster hiring a rehabilitation nurse? Our impression is that this is a calculated maneuver on her part. Yes, the nurse costs money. But if the nurse is effective the doctor may order less treatment and return you to work sooner than he ordinarily would. All of that saves the adjuster money.

Keep in mind that your adjuster is probably under pressure from her supervisors to close out files as quickly as practicable. She’s also probably getting an earful from a lot of injured workers. If she’s been around any length of time she may well be feeling a little burnt out or jaded as to the complaints of workers’ compensation claimants.

The other thing to understand is that your adjuster is a professional. She knows the ins and outs of workers’ compensation. She undergoes rigorous annual training and periodic updates on the law. She is a professional. You are probably very very good at what you do (or did). But you aren’t a workers’ compensation professional. Putting it bluntly: you’re no match for her. You won’t even necessarily know where’s she’s cutting you short if she does. And this is without her even turning to a defense attorney to assist.

The bottom line is that workers’ compensation is one of those areas where you can be underwater without even knowing you are. That’s how complex the law is. It is never ever a mistake to call a lawyer. You may not need to hire one. But you do need to speak with one.

How is my pay calculated?

Workers' Compensation

Your weekly checks – if you’re totally out of work – are called temporary total disability checks (TTD). If you think about it this makes sense… it isn’t permanent but you are completely out of work. These TTD check are two-thirds of your average weekly wage (AWW, and subject to maximum amounts for any given year). You’re AWW is the average of what you earned over the last 52 weeks with that employer taking into account overtime, bonuses, absences of less than a week, raises, etc. It’s extremely common for an insurance company to set your AWW at your base pay and ignore any overtime, per diems, etc. But it’s critical to get this figure right. It’s the key to your entire claim. With that in mind, it may not be wise to trust the adjuster to correctly determine the amount.

The adjuster wants all my medical records for the last 10 years. Seriously?

Workers' Compensation

Don’t get us started. We think this is a complete intrusion on your privacy. But the Industrial Commission routinely authorizes it. Why a woman needs to give her gynecological records to an adjuster when she has a torn rotator cuff is beyond our understanding. What makes this worse? There is nothing – absolutely nothing – that prevents the adjuster from distributing copies of these records to that woman’s male coworkers. I’m not sure the Industrial Commission thinks this through. For instance, we’ve gotten the Industrial Commission to side with us when adjusters and employers try to get copies of an injured workers’ record from a marriage counselor. The likelihood of unnecessary embarrassment far outweighs the chance that someone told their pastor that they were so upset with their spouse leaving them that they were going to risk going to prison by faking an on-the-job accident. It just doesn’t happen.

Now, if you’ve had two prior surgeries on your shoulder we agree that those records are relevant if you’ve got a new shoulder claim. But not if you have a knee claim. We make every effort to limit this horrible intrusion. If you’re concerned about your privacy please call us. Let us intervene to limit what gets turned over to the insurance company.

Why can’t the adjuster pay me on time?

Workers' Compensation

In most cases there is absolutely nothing that prevents an adjuster from paying you on time. It’s just a matter of her interest and inclination in doing so.

In some cases when the employer is self-insured they must send money periodically to the insurance company. In those instances we’ve heard adjusters use the excuse that they are waiting for money from the employer but that’s just an excuse. It is the adjuster’s responsibility to make sure she has proper reserves.

More often we suspect that the adjuster is toying with you. She knows that under current North Carolina law the check isn’t due for ten days after the time you missed work. Thus, if you missed the first day of the month the adjuster doesn’t have to pay you until the tenth. What if she doesn’t? Well nothing happens immediately. If she’s fourteen days late – the twenty-fourth- then the Industrial Commission “may” impose a 10% penalty. Thus, if the adjuster sits on your $500 weekly check for three weeks the NCIC might sanction her $50.

Mind you, the Industrial Commission is open to waiving that penalty if the defendants present compelling evidence that they shouldn’t be fined. In the past we’ve seen the Industrial Commission waive the late penalty for reasons which included “I forgot”, “my attorney didn’t tell me to”, and “I put in an order for it to be mailed… something must have happened.” More likely than not the NCIC will impose the penalty but questions certainly remain as to whether that’s a significant deterrent. We’ve had luck with taking a different approach and have obtained orders requiring an adjuster to pay timely. If there is a consistent failure to comply with this order we’ve been able to get sanctions with some teeth to them.

The doctor has ordered a test but the adjuster isn’t approving it. Why?

Workers' Compensation

There’s no simple answer to this but here are a few possibilities. First, she’s lazy or procrastinating or overworked. Maybe.

Second, she’s in denial that the test is actually necessary. She may be hoping that you spontaneously get better without the test. That occasionally happens but not often. Most experienced workers’ compensation doctors aren’t just ordering tests randomly. They don’t order tests they don’t think are necessary. But some adjusters act like they know more about modern medicine than someone who went to medical school.

Third, she may have an internal review that has to be done before the tests can be authorized. Some insurance companies have an internal “utilization review” performed by an in-house “doctor” to second guess the doctor who ordered the tests.

Fourth, the adjuster may be trying to line up a second opinion with another doctor who may say the test isn’t necessary. You may ask yourself: would an adjuster really pay an extra month of weekly benefits, pay hundreds of dollars to a rehabilitation nurse to set up a second opinion, and pay hundreds more outside of the Industrial Commission medical fee guidelines, just in the hope of avoiding a $750 test? The answer is yes.