For most people going through their first Workers’ Compensation (“WC”) claim, the process can be quite confusing. After getting injured while on the job, you complete a heap of paperwork. Next, you provide copies of your paystubs and start getting a check every few weeks for less than your regular pay. This continues while you wait for more paperwork to be completed for your next medical appointment. Does this situation sound familiar?
The WC claim process gets even more confusing. You get a letter stating you need to visit an Independent Medical Examination (“IME”). If you don’t, your WC benefits will be terminated. Or, maybe the letter states your benefits have already been terminated because your doctor says you’re at Maximum Medical Improvement (“MMI”). What gives? Why did this happen? Do I need a lawyer?
Sadly, most people with WC claims become victims of a system they blindly trust believing they’ll be taken care of. One way to avoid these pitfalls is having an advocate familiar with the details of the WC claim process ensure your rights aren’t being infringed on. But, at one point do you reach out to an attorney for a consultation on your WC claim?
Montana law specifically requires WC insurers to make a decision about a request for benefits within 30 days of receiving the request (Montana Code Annotated § 39-71-606). Montana law also places a general obligation on WC insurers to acknowledge communications from and insured and respond in a reasonable amount of time (Montana Code Annotated § 33-18-201). The failure by a WC insurer to meet these requirements may create an opportunity to be on offense against your WC insurer and get results in your claim.
Speaking with an attorney will allow you to present your situation to a professional who knows the difference between an insurer failing to meet legal obligations and an overworked insurance adjuster. The solution may be as simple as figuring out a more responsive way to communicate with your adjuster. The solution may be as complex as suing the insurer for their bad behavior.
Under Montana Law a WC insurer can request a claimant undergo an examination by a medical professional at the insurer’s expense (Montana Code Annotated § 39-71-605). Although insurers call these doctors "Independent" medical examiners, they are often far from independent. The insurance company's goal may be to develop medical evidence to use against you, so they will often seek out-of-state doctors, "hired guns," who can be relied on to provide an opinion that is biased against you. After a quick examination, these doctors will often render a medical opinion that the insurer will use to terminate your benefits. To make matters more difficult, if you refuse to comply with an IME request, your benefits can be terminated as well.
Calling an attorney before the IME is one of the best steps you can take to ensure you are prepared for the IME. Having an advocate on your side who understands the IME process and your rights in that process can level the playing field when you’re going up against the insurers hired medical gun.
Under the law, being at MMI means you are at “a point in the healing process when further material functional improvement would not be reasonably expected from primary medical services (Montana Code Annotated § 39-71-116).” Essentially, you are at the point where your injury has healed so much so that continued medical care will not reasonably improve your outcome anymore.
This is a critical point in any WC claim because once you’ve reached MMI, your insurer can stop paying benefits and may begin making offers to settle your WC claim. You may even be in a situation where your condition at MMI does not allow you to return to your job because of the severity of your injuries.
Contacting an attorney at this point is a good step to take so you can make informed decisions about bringing your claim to a close. Often, injured individuals are not actually at MMI when a medical professional says they are. An attorney will fight for you in this situation so you can continue receiving treatment. An attorney will also know how your condition at MMI will affect the benefits you deserve if you want to settle your claim.
Montana law requires insurers to give a 14-day written notice when terminating a claimant’s benefits (Montana Code Annotated § 39-71-609). Usually, the insurer sends this notice once they learn the claimant has been released back to work and/or the claimant has been found to be at MMI. Typically, after a claimant receives treatment for their injury for a number of months, they’re sent to an IME. Based on the results of the IME,the insurer terminates benefits. This can put you in a very tough spot financially and make an already stressful situation even worse.
It is also important to remember that you have the opportunity to challenge a denial of WC benefits. There is a particular series of steps you have to take to do this and a lawyer will be able to guide you. There is also a way to have your bi-weekly benefits reinstated for a short period of time while you dispute the insurer’s actions (Montana Code Annotated § 39-71-610). Under Montana law, you have two years from the date of a denial of benefits to pursue a claim before the WC judge (Montana Code Annotated § 39-71-2905). Securing representation quickly after your benefits are denied is the best way to maintain all your options if your WC benefits have been terminated.
Dealing with your WC can be time consuming, frustrating, and confusing. If you think you need help and guidance for any reason, you should consider obtaining representation. Doing so will mean that you have an advocate on your side who can guide you through the process while fighting for your rights and the treatment you may need to recover.
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