Why am I being treated so badly by the Workers' Comp System? (Part One)
First of all, you need to know some of the players in the so called Workers' Compensation System. In Florida, when you get injured on the job you are automatically considered a Claimant or Injured Worker. As the Claimant, you are entitled to two main categories of benefits; necessary medical care and lost wages or indemnity. You only get medical care that is absolutely necessary and dozens of rules apply to what treatment you do or do not get. You don't ever get all of your lost wages and, again, dozens of rules apply that control what you may or may not get. Most people need a workers' compensation lawyer to get the most treatment and lost wages out of the system.
O.K., so you are the Claimant. Lucky you! Your employer is the next party you need to understand. In ordinary circumstances, you provide services (work) and you get paid (hourly, salary, or commission). But, these are not ordinary circumstances. One minute you are an asset to your employer, then due to an accident (regardless of whose fault it may be) and suddenly your are a liability. The employer has to call in the claim to their workers' compensation insurance company. If the employer does not do this or gives incorrect or incomplete information to the insurance carrier, then you need an attorney who actually practices workers' compensation. Very few attorneys practice this field of law.
Now you get the pleasure of dealing with the next player in the system, the adjuster. Even kind and conscientious adjusters can create problems for you. There are some, on the other hand, who take delight in denying benefits. Fortunately, the bad ones are rare and most adjusters do try to do the right thing, but they work in a difficult system. They are overworked, underpaid, and the law that governs what they owe you is very restrictive. So, if the adjuster is doing their job and fulfilling their responsibility to their employer, they often have to deny benefits. They control what doctors you see and control the money. The adjuster may hire a Nurse Case Manager to help them with the provision of medical benefits. Difficulties with either the adjuster or the nurse can often be resolved with the help of your workers' compensation - w/c attorney.
The adjuster works for an insurance company, not a charity or a governmental agency. They are in business to make a profit! The business model for insurance companies is complex, but to put it simply, they collect large premiums, combine them state-wide and invest them, and then pay out on as few claims as possible. They then keep the monies collected or invested that are not paid out on claims. Their "job," therefore, is to pay as little as possible on any given claim and deny claims in their entirety. That increases the profit of their company. They are not evil and they are not "out to get you," but the adjuster is fulfilling their job responsibilities by reducing the amount they pay on your claim, thus reducing or eliminating your benefits. You need to understand their role in the "system." You need an attorney to resolve disputes with the adjuster. While a denial of benefits is "just business" to the adjuster, to you it is very personal. Your finances and, even more importantly, your health are at stake. Check back for more articles on this and related topics.