The workers’ compensation process was designed to be administrative and somewhat easy for laypeople to navigate, but if your case isn’t “cut and dried”, it may be in your best interest to retain a workers’ compensation lawyer. This guide sets out the most common factors to determine whether or not you should seek legal advice and/or representation.
For information on workers’ compensation benefits, you can take a look at the State of California Division of Workers’ Compensation webpage or visit our FAQ page.
Do I Need a Workers’ Comp Lawyer? – When Is Hiring a Lawyer Probably Not Necessary?
Insurance companies don’t dispute all workers’ compensation claims. Chances are, the insurance company will likely not dispute your workers’ compensation claim if you can demonstrate that your injuries were clearly work-related and don’t or won’t result in:
- Permanent injuries
- Long periods off of work
- Extensive medical treatment
If, for example, you have a desk job, sprained your ankle because you slipped on some water that had been spilled in the lunch room – and your doctor told you to ice your ankle, rest for a couple of days, and take pain relievers if necessary – the insurance company would probably cover your trip to the doctor. This is presuming that you were able to return to work relatively quickly and had no further issues to claim.
When You Should See a Workers’ Compensation Lawyer
If, for whatever reason, you end up in a dispute with the insurance company over your claim, it is recommended that you seek legal representation. Legal expertise is most often required to mount a proper challenge to the insurance company’s position. The process may involve getting an independent medical examination/assessment, hiring expert witnesses, and taking depositions.
For these reasons, talk to a lawyer if any of the following apply to you.
The Insurance Company Denies Your Claim
There are a number of reasons an insurance company may deny your claim. Some of the main reasons are:
- No one else witnessed your injury.
- You didn’t report your injury right away.
- What you said in your accident report and what you told your doctor are not consistent.
- You were let go from your employment prior to filing your claim.
- You refused to provide a recorded statement or sign medical authorizations.
From the insurance company’s perspective, any or all of these things can be interpreted to mean that you are not being entirely truthful or are hiding something.
There is a workers’ compensation appeal system, which can vary from state to state, but you are usually required to file formal paperwork, gather evidence to support your side, and present your side at a formal hearing. It would be best to have a lawyer in your corner when you do these things.
You Have a Pre-Existing Injury or Condition With Respect to the Injured Body Part
In most cases, the insurance company will argue that your injury was the result of your pre-existing injury or condition, not work-related, especially if your injury was caused by repetitive stress (gradual and not caused by a single work-related accident). A good example of this type of injury is carpal tunnel syndrome.
A case like this involves a high level of medical evidence, much of which is very technical, and having legal representation is definitely recommended.
You Receive Other Government Benefits
In many cases, if you are receiving any other health-related, monetary benefits from the government – such as SSDI (Social Security Disability Insurance) benefits, the amount of those benefits will be reduced if you also receive workers’ compensation benefits. The problem is that in the end, you may find yourself out of pocket because the benefits have decreased too much. The two systems may work on different definitions, resulting in some inconsistency with the numbers.
Having a lawyer if this happens is a good idea, because they can help minimize how much the SSDI payments will be decreased. They can also help you best set aside some of your workers’ compensation benefits for future medical treatment if you are eligible for Medicare.
You Are Not Getting the Medical Treatment You Need
Insurance companies may deny certain medical treatments, such as surgery, especially if they cost a lot. Alternatively, the insurance company may significantly delay approval of these treatments.
If you have retained a lawyer, they can negotiate with the insurance company or provide it the necessary evidence for it to approve of medical treatments you need for your work-related injury. If it’s a matter of delay, your lawyer can put pressure on the insurance company to approve the treatments more quickly.
Your Injury Affects Your Ability to Work
If you have been rendered unable to work again because of this injury, you will need to get the maximum workers’ compensation benefits to which you are entitled, and to make sure they are structured in a way that lasts in the future. Insurance companies tend to resist granting maximum benefits.
Your lawyer is best suited to negotiate with the insurance company. If you have to change careers because of your injury, they can help you get training for the new career.
You Need to Challenge Your Permanent Disability Rating
When your doctor declares that you have reached the MMI (maximum medical improvement) – when further treatment isn’t likely to help your injury – they will evaluate your ability to perform normal activities. This is to determine whether you are permanently disabled, and involves a physical exam and tests on your range of motion, balance, and how much you can lift, among other things.
Your doctor will give you a permanent disability rating. However, the insurance company may dispute it and request an independent medical exam – usually by a doctor of its choosing. Unsurprisingly, the permanent disability rating assigned by this doctor may be lower than what your doctor gave you, which will affect the amount of benefits the insurance company will pay you.
A workers’ compensation lawyer may be invaluable to getting you a fair settlement or persuading a judge that you deserve the higher permanent disability rating.
You Need to Have a Workers’ Compensation Hearing
If you are heading towards a workers’ compensation hearing, it usually means that the insurance company refuses to settle with you for a fair amount. This is a formal hearing that is conducted similarly to a trial, so there will be rules of evidence, legal procedure, and legal precedents argued and followed. You would be at a major disadvantage if you did not have legal representation.
Lawyers are trained to make legal arguments, and the insurance company will most likely have a lawyer retained to represent it.
Is Hiring a Workers’ Compensation Lawyer Worth It?
Of course, your workers’ compensation lawyer will have to get paid, but they don’t charge you hourly or collect a retainer fee like lawyers in most other areas of law. In other words, you don’t pay legal costs upfront. Workers’ compensation lawyers charge a contingency fee, which is a percentage of whatever workers’ compensation benefits they help you to recover.
The percentage a workers’ compensation lawyer is allowed to collect from a client’s workers’ compensation benefits will depend on the state. In California, the percentage is typically between 9% to 12%, depending on how complicated the case is. You can use the LexisNexis Workers’ Compensation Legal Fees Calculator to get a sense of how much your workers’ compensation lawyer might cost.
Since workers’ compensation lawyers tend to get you higher benefits than if you were on your own, in many cases, even after they take out their fees from your reward, you will receive a higher amount in benefits.
If you have any questions about whether you should hire a lawyer for your workers’ compensation claim, or to find out more about how much your case may cost, contact us today.