Workers’ compensation is a vital protection for employees who suffer injuries or illnesses on the job. But have you ever wondered, “how is workers’ compensation pay calculated“? Understanding the calculation process can help you ensure that you receive the appropriate compensation for your work-related injury or illness.
There are several factors that can influence how your workers’ compensation pay is calculated. Understanding these factors can help you have a better idea of what to expect in terms of compensation for a work-related injury or illness.
Your average weekly wage is a key factor in determining your workers’ compensation pay. This is usually calculated by looking at your earnings over a specific period of time, such as the 52 weeks leading up to your injury. The higher your average weekly wage, the higher your compensation benefits are likely to be.
The extent of your disability is another important factor in determining your workers’ compensation pay. Disability can be classified as temporary or permanent, and partial or total. If your injury or illness leaves you unable to work at all, you may be entitled to receive a higher compensation rate compared to someone with a partial disability.
Workers’ compensation laws can vary from state to state, and each state has its own guidelines for calculating compensation benefits. These laws outline the maximum and minimum compensation rates, as well as any specific rules or regulations that may affect your pay.
Your workers’ compensation pay may also cover medical expenses related to your injury or illness. This can include doctor’s visits, hospital stays, surgeries, medications, and rehabilitation costs. The amount and duration of medical benefits can vary depending on the severity of your condition and the recommended treatment.
In some cases, workers’ compensation may include vocational rehabilitation services to help you return to work or find suitable employment if you are unable to continue in your previous job. These services can include job training, job placement assistance, and vocational counseling.
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 checks are two-thirds of your average weekly wage (AWW), and subject to maximum amounts for any given year.
Your 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.
Calculating workers’ compensation pay can be a complex process, and there are several common mistakes that can occur. It’s important to be aware of these mistakes to ensure accurate and fair compensation for injured workers.
One common mistake is miscalculating the average weekly wage (AWW). The AWW is used as a basis for determining the compensation amount, and it is calculated by taking the worker’s earnings over a specific period of time and dividing it by the number of weeks in that period. However, errors can occur when calculating the AWW, such as excluding overtime pay or not considering all sources of income. These mistakes can result in a lower compensation amount than what the worker is entitled to.
Another mistake is failing to consider the correct disability rating. The disability rating is a percentage that represents the extent of the worker’s impairment or loss of function. This rating is used to calculate the compensation amount. However, if the rating is not accurately determined or if the wrong rating is used, it can lead to an incorrect compensation amount.
Additionally, not considering all eligible benefits can be a mistake in calculating workers’ compensation pay. There are various types of benefits that injured workers may be entitled to, such as medical expenses, rehabilitation costs, and vocational training. Failing to include these benefits in the calculation can result in an incomplete and inaccurate compensation amount.
Lastly, failing to keep up with changes in workers’ compensation laws and regulations can lead to mistakes in calculating pay. These laws and regulations can vary by jurisdiction and may be updated periodically. It’s important to stay informed and ensure that the correct guidelines and formulas are being used to calculate compensation.
To avoid these common mistakes, it is recommended to seek the guidance of a workers’ compensation attorney or a knowledgeable professional who can assist in accurately calculating workers’ compensation pay. By doing so, both employers and employees can ensure that the compensation amount is fair and in compliance with the law.
Have you ever had difficulty receiving payment from an insurance adjuster in a timely manner? It can be frustrating when you’re waiting for the funds you deserve after a loss or accident, only to be met with delays and excuses. But what exactly causes these delays? Why is the adjuster not paying you on time?
In most cases there is absolutely nothing that prevents an adjuster from paying you on time. It’s just a matter of their 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. They 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 they don’t? Well, nothing happens immediately. If they’re fourteen days late – the twenty-fourth day from the date of payment- 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.
No, it is not allowed for adjusters to not pay on time. Adjusters are responsible for evaluating insurance claims and determining the appropriate amount of compensation to be paid to policyholders. This process should be carried out in a timely manner and in accordance with the terms and conditions of the insurance policy.
Insurance companies have a legal obligation to act in good faith and deal fairly with their policyholders. This includes promptly investigating claims, making a fair assessment of the damages, and providing timely payment. Failure to do so can result in legal consequences, such as breach of contract claims or bad faith lawsuits.
However, there may be certain circumstances that can cause delays in the payment process. For example, if there is a dispute over the coverage or the amount of damages, the adjuster may need additional time to gather evidence and negotiate with the policyholder. Additionally, if there are administrative issues or technical difficulties, it could also cause delays in the payment process.
If you are experiencing delays in receiving payment from an adjuster, it is important to communicate with them and inquire about the reasons for the delay. In some cases, it may be a simple oversight or a misunderstanding that can be resolved through open dialogue. However, if you believe that the adjuster is intentionally delaying payment without valid reasons, you may need to seek legal advice and take appropriate action to protect your rights as a policyholder.
Improving the timeliness of payments from an adjuster can be a frustrating task, but there are several steps you can take to increase the chances of receiving your payment on time.
Make sure to provide all the necessary documentation and information required by the adjuster. This includes invoices, receipts, and any supporting documents that validate your claim. Clear and organized documentation can help expedite the payment process.
Don’t hesitate to follow up with the adjuster to inquire about the status of your payment. Politely and professionally remind them of the agreed-upon payment terms and deadlines. Regular communication shows your commitment and can prompt the adjuster to prioritize your payment.
Before starting any work or providing services, it’s essential to establish clear payment terms with the adjuster. Clearly outline the payment schedule, due dates, and any penalties or late fees for delayed payments. Having these terms in writing can help hold the adjuster accountable and ensure timely payments.
Developing a positive and professional relationship with the adjuster can go a long way in improving the timeliness of payments. Be responsive, cooperative, and maintain open lines of communication. A good relationship can encourage the adjuster to prioritize your payment and resolve any potential issues promptly.
If you have followed all the necessary steps and still face delays in payment, it may be necessary to escalate the issue. Contact a supervisor or manager within the adjuster’s organization and explain the situation. They may have the authority to expedite the payment or provide a resolution.
In extreme cases where all other attempts have failed, you may need to consider legal action. Consult with an attorney specializing in insurance or contract law to explore your options and determine the best course of action.
Have you ever been in a situation where your doctor has ordered a crucial medical test, but your adjuster was not approving the test ordered by the doctor? It can be incredibly frustrating and leave you wondering why they are denying you the necessary care. Well, you’re not alone. Many people face this issue, and understanding the reasons behind these denials is essential in advocating for your health.
In this article, we will delve into the common reasons why insurance adjusters may deny test approvals. By understanding these factors, you can be better prepared to challenge denials and ensure that you receive the necessary tests for accurate diagnosis and effective treatment.
There’s no simple answer to this but here are a few possibilities. First, they’re lazy or procrastinating or overworked. Maybe.
Second, they’re in denial that the test is actually necessary. They 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 typically 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, they 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.
When it comes to advocating for the approval of medical tests, there are several strategies that can be employed to increase the chances of getting the test approved by the adjuster. Here are a few possible strategies:
One of the most important strategies is to gather and provide detailed medical documentation that clearly supports the need for the test. This can include medical records, test results, and expert opinions that explain the medical necessity of the test and its potential impact on the patient’s diagnosis and treatment.
It is crucial to establish open lines of communication with the adjuster handling the case. This can be done through phone calls, emails, or in-person meetings. By explaining the importance of the test and providing supporting evidence, it may be possible to convince the adjuster of its necessity.
It is important to work closely with the doctor who ordered the test and seek their support in advocating for its approval. The doctor can provide additional information, clarification, and medical reasoning that can strengthen the case for the test.
In some cases, involving a patient advocate or a medical professional who specializes in insurance claims can be beneficial. These individuals can provide guidance, support, and expertise in navigating the insurance process and advocating for the approval of the test.
If the initial request for the test is denied, it is possible to appeal the decision. This involves submitting additional documentation, providing further justification, and presenting a strong case for why the test is necessary. The appeals process may vary depending on the insurance provider, but it is an important step in advocating for the approval of the test.
If you find yourself in a situation where the doctor has ordered a test, but the insurance adjuster isn’t approving it, you may be wondering if it’s time to contact an attorney. While not every situation requires legal intervention, there are certain circumstances where obtaining legal advice can be beneficial.
But generally, if the adjuster is not approving a test that your doctor has ordered, it may be in your best interest to contact an attorney. They can guide you through the legal process, advocate for your rights, and help ensure that you receive the necessary medical treatment.
Have you ever been in a situation where your insurance adjuster recommended a second opinion after the doctor that they gave has already recommended surgery? It can be frustrating and confusing to understand why this is necessary. But don’t worry, you’re not alone.
It’s important to understand that insurance adjusters are not medical professionals, and their job is to ensure that the insurance company is not paying for unnecessary medical procedures. In some cases, a second opinion can help confirm the necessity of surgery and ensure that the insurance company is making a justified payment.
In this article, we will dive deeper into why insurance adjusters may require a second opinion and how it can affect your medical treatment and insurance coverage.
They shouldn’t, but under the current set of laws there really isn’t much of a limit to what the adjuster can request. It rarely works to simply refuse to attend a second opinion. On the other hand, we’ve had some success convincing the Industrial Commission that the adjuster is abusing their privileges.
And under a law which escaped revision by Gov. McCrory, if an adjuster wants a second opinion on a surgical recommendation they must move quickly. While the Industrial Commission generally grants additional time the law requires that the second opinion be scheduled (but not necessarily completed) within ten days of the original recommendation for surgery. We are very aggressive about scheduling expedited hearings over this issue.
There are several reasons why an adjuster may need to seek a second opinion, even if their own doctor has recommended surgery. First and foremost, it is important to understand that insurance adjusters have a responsibility to the insurance company to ensure that claims are valid and necessary. Seeking a second opinion allows the adjuster to gather additional information and ensure that surgery is indeed the best course of action.
Additionally, seeking a second opinion helps to mitigate the risk of unnecessary surgeries or potential medical malpractice. Surgery is a major decision and it is important to have multiple medical professionals review the case to ensure that it is the most appropriate and necessary treatment option.
Lastly, seeking a second opinion can also help to build trust and credibility with the claimant. By taking the time to gather multiple medical opinions, the adjuster is demonstrating a commitment to fairness and thoroughness in the claims process.
Insurance companies have a responsibility to thoroughly evaluate claims and make informed decisions. By seeking a second opinion, they can verify the necessity of the recommended surgery, assess the potential risks and benefits, and determine if alternative treatments or therapies are available.
The second opinion also helps to mitigate the risk of unnecessary surgeries or procedures, which can be costly for both the insurance company and the claimant. It ensures that the recommended treatment aligns with established medical standards and guidelines.
While it is common for an adjuster to request a second opinion when a doctor recommends surgery, it is important to understand that you have the right to refuse getting a second opinion. However, it is essential to consider the reasons behind the adjuster’s request before making a decision.
You were in an accident and now you’re dealing with insurance adjusters. They’re telling you that you need to see a different doctor, but the catch is that the doctor is halfway across the state. You’re wondering if this is even legal. Can an adjuster make you to travel for medical appointments?
Sometimes, and if they can get away with it. A while back a well-known neurosurgeon based in Raleigh spoke at a closed-door meeting with adjusters at a meeting sponsored by a law firm, which represents mostly insurance companies and employers. During the course of his presentation he stated that he believed a lot of injured workers underwent unnecessary surgeries and ended up being out of work longer than necessary as a result. What happened next? Clients who lived in Mount Airy, in Lexington, even in Charlotte were being sent to him for second opinions.
This happens more often than you would believe. In this particular case we objected to the Industrial Commission. The defense attorney, coincidentally a partner in the firm that sponsored the private meeting, argued that the law regarding second opinions didn’t require that the doctor be fair or neutral. The only limitation was in terms of geographical reasonability.
The Industrial Commission seems to have bought into this theory. Your best defenses against a second opinion are that it’s too far away and that the adjuster has already had a couple of second opinions. At some point the adjuster has to concede that she’s only shopping for an opinion that she wants to hear and isn’t really looking for sound medicine anymore. While that seems patently obvious to some people it’s considered bad form to admit to it when you’re at the Industrial Commission.
To be fair, we have our own lists of doctors as well. One advantage of our law firm is that we’ve been keeping records and notes on doctors, adjusters, rehabilitation nurses, etc., for years now. We know which ones tend to unnecessarily favor the employers and insurance companies and we know which ones put their patient’s interests first. So, when it’s our turn to pick a doctor, we know who we’ll recommend.
The answer to this question depends on several factors, including the state in which you live, the terms of your insurance policy, and the severity of your injuries. In general, an adjuster cannot force you to travel an unreasonable distance for medical appointments.
Most states have laws that require insurance companies to provide reasonable access to medical care for their policyholders. This means that if you live in a rural area with limited medical resources, the adjuster may need to make arrangements for you to receive care in a nearby city or town.
However, if the adjuster asks you to travel a significant distance for routine appointments or treatments that could be provided closer to your home, you may be able to push back and request alternative arrangements. It’s important to communicate with your adjuster and healthcare providers to find a solution that works for everyone.
If you feel that your adjuster is making unreasonable demands or violating your rights, you may want to consult with an attorney who specializes in insurance law. They can provide guidance on your legal options and help you protect your rights as a policyholder.
As an insurance adjuster, it’s common to require claimants to attend medical appointments in order to properly assess their injuries and determine the appropriate compensation. However, if you are unable or unwilling to attend a medical appointment that is scheduled, you may be wondering if you have the right to refuse to travel.
The short answer is yes, you can refuse to travel for medical appointments. That being said, refusing to attend medical appointments without a valid reason can negatively impact your claim. Your adjuster may view this as noncompliance and may question the legitimacy of your injuries. It is important to work with your adjuster and medical professionals to find a solution that works for everyone involved.
If you’re facing a situation where an adjuster is requiring you to travel for medical appointments, you may be wondering whether or not you should seek the help of an attorney. While it’s not always necessary to hire an attorney, there are some situations where it can be beneficial.
Ultimately, the decision to hire an attorney will depend on your individual circumstances. If you’re unsure whether or not you need legal assistance, it’s always best to consult with a qualified attorney who can help you understand your options and make informed decisions.
