| Workers' Compensation
Injured Workers
What is (are)...
- an admission of
liability?
An Admission of Liability is a statement by an
insurance company acknowledging responsibility for payment of
benefits outlined in the admission. Once an admission of
liability is issued, an insurance company is bound to pay the
benefits set forth in the admission until it can terminate
benefits under the law. If you believe your benefits have been
calculated incorrectly or terminated improperly, review the
following information:
How
to...calculate your average weekly wage and what to do if you
believe your wages have been reported incorrectly and
What is...the criteria for terminating
benefits? If, after reviewing this information, you
believe there is an error, contact the Division of Workers’
Compensation and ask to speak with a Claims Manager.
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A Notice of Contest is a statement
by an insurance company denying responsibility for payment of
benefits. The basis for the denial is outlined in the notice of
contest. If the reason for the denial is further
investigation, you may want to contact the insurance
adjuster handling your claim to determine what information is
lacking and how you may assist in obtaining the necessary
information to expedite review. The name and phone number of
the adjuster should appear on the Notice of Contest form.
If your claim has been denied, you may be
responsible for all the medical bills associated with the
illness or injury. (You may then be eligible for coverage
through your private health care insurance policy.) If you
believe your claim has been incorrectly denied, there are
several options available to you.
See
What
is...a Prehearing Conference? and What
is...an
Administrative Hearing? below. If your claim is
denied and you want to request an expedited hearing, you
must file an Application for Hearing form within 45 days of the
date of mailing of the Notice of Contest form.Whatever the basis for the denial, the fact
remains that the claim has been denied. If you wish to pursue a
claim for workers’ compensation benefits, it will be necessary
for you to actively prosecute the claim and exercise the options
that are afforded you under the law.
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Prosecuting a claim means to follow through
with actions to obtain benefits until a final determination is
made. Prosecution of a claim may include requesting a hearing,
participating in a prehearing conference for the purpose of
resolving issues, engaging in good faith settlement
negotiations, obtaining medical evaluations and reports
necessary to prove the case, etc. Under the Colorado Workers’
Compensation Act, timeliness of prosecution is also a
factor. Failure to take action to prosecute a claim for a
period of 6 months will be considered failure to prosecute and
may result in the closure of a claim. See C.R.S.
8-43-207(1)(n).
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An order is a written decision by an
Administrative Law Judge or the Director of the Division of
Workers’ Compensation that awards or denies benefits, imposes
penalties, or directs the parties to take certain actions, such
as close a claim, or respond to a request for information. An
order will address a specific issue or issues which one or both
parties have brought forward to be reviewed and decided.
Certain orders, (those which award or deny benefits or impose
penalties) may be appealed. If you disagree with an order that
awards or denies benefits and wish to appeal, be sure to follow
the instructions on the order and file your appeal (called a
Petition to Review) exactly as described.
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- temporary
disability benefits?
Individuals who lose more than three days
or three shifts of work as the result of a work related injury
or disease may be eligible to receive a form of wage replacement
beginning on the forth day of work loss. This benefit is called
temporary disability. Once started, temporary benefits must be
paid every two weeks until terminated in accordance with the
law. There are two types of temporary disability benefits:
Temporary total disability is a benefit
that is available when an individual has been off work for
more than three days or three shifts as the result of the
injury. The benefit rate is based on two-thirds of the
worker’s average weekly wage at the time of injury up to a
maximum established by law. The initial three days of work
loss are not payable as compensation unless the injured
worker is off for more than two weeks.
- temporary partial disability?
Temporary partial disability is a
benefit that is available for partial wage loss when an
individual has returned to work at less than full wages.
Benefits are calculated at two-thirds of the difference
between the worker’s average weekly wage at the time of
injury and his/her current earnings.
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Temporary disability benefits will
terminate when:
- You return to work at your pre-injury wage
- You are given a release to return to your regular work by your authorized
treating doctor
- You are given written release by your authorized
treating doctor to return to modified work, your employer
makes you a written offer of such work, and you fail or
refuse to begin the work*. You are allowed 3 business
days to return to work in response to an offer of modified
duty employment.
- You fail to appear at a rescheduled medical appointment
following notification that such failure will result in
suspension of temporary disability benefits.
- Your authorized treating doctor determines that you have
reached maximum medical improvement (MMI). MMI means that
the injury or disease causing your disability has become
stable and no further medical treatment will improve the
condition
*If you work for a temporary help
contracting firm, a business which hires people to work for a
third party, you are entitled to receive only one written offer
of modified work. Any future offers do not have to be in
writing. The offer of work must be approved by your doctor.
You are allowed at least twenty-four hours, not including
Saturday, Sunday, or a legal holiday, to respond to the offer of
work. If you do not accept the offer of work, your benefits may
stop.
Temporary disability benefits may also be
terminated by a petition. See
What is...a Petition
to Modify, Terminate or Suspend?
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- a Petition to
Modify, Terminate or Suspend?
An insurance company may request permission
to modify, terminate or suspend temporary disability benefits
for reasons which fall outside of the standard criteria (see
What is...the
criteria for terminating temporary total disability benefits?)
by filing a petition or request to terminate benefits
with the Director of the Division of Workers’ Compensation and
stating the basis for the request. The form must be
simultaneously filed with the injured worker and his or her
attorney along with a response form. If the injured worker
fails to object in writing within 20 days of the date of the
petition, the request may be granted and benefits may be
modified or terminated. If a timely objection is received, the
insurance company must then set the matter for hearing before an
administrative law judge or wait until benefits may be
terminated under the standard criteria set by statute.
See
Rule 6, Suspension, Modification or Termination of
Temporary Disability Benefits by a Petition.
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-
maximum medical improvement (MMI)?
“Maximum medical improvement" means a point
in time when a physical or mental injury has become stable and
when no further treatment is reasonably expected to improve the
condition. The possibility that the condition may get better or
worse over time or the fact that a person is receiving medical
maintenance treatment does not affect a determination that s/he
has reached maximum medical improvement.
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- permanent partial
disability?
Permanent partial disability means a
permanent loss of function (or impairment) to a body part or a
body system (i.e. nervous system, respiratory system, digestive
system, etc.), that can be measured in accordance with
The
AMA Guide to the Evaluation of Permanent Impairment (Third Ed.
Rev.) and which directly resulted from the injury or
occupational disease. A physician trained (accredited) in
evaluating impairment determines the amount of permanent
impairment that has resulted from the injury or disease and
assigns a number in the form of a percentage.
There are two types of permanent partial
disability awards under the Colorado Workers’ Compensation
Act.
Scheduled Injuries: Permanent impairments to arms, legs, hands,
feet, fingers, toes as well as vision and hearing are called “scheduled
injuries” because these injuries are compensated based on a schedule. The
schedule can be found at
C.R.S.
8-42-107 (2)
and assigns a value to each of these body parts. The value is expressed in
weeks. For example, the little finger of the hand is assigned a value of 9
weeks. To determine the amount of an award to the little finger, 9 weeks will be
multiplied by the percentage of impairment (or loss of function) the physician
determines has resulted from the injury. This amount is then multiplied by the
compensation rate in effect at the time of the injury. For example, if the
physician determines you suffered a 50% permanent impairment to your little
finger, 50% of 9 weeks equals 4 ½ weeks. If the injury occurred between July 1,
2003 and June 30, 2004, when the weekly compensation rate for scheduled injuries
was $207.35, then the award would be calculated in the following manner:
$207.35 x 4.5 weeks = $933.08
In another example, the
physician has determined that as the result of an injury to
your foot, you have sustained 10% permanent impairment to
the whole foot. The injury occurred in August, 2004 when
the compensation rate for scheduled injuries was $212.32 per
week. The value of a foot below the ankle on the schedule
is 104 weeks. Since impairment of the foot was rated at
10%, then 104 x 10% = 10.4 weeks and the permanent partial
disability award is calculated as follows:
$212.32 x 10.4 weeks = $2208.13
Non-Scheduled Injuries: Permanent impairment to parts of the body
or body systems that are not listed on the schedule are called “non-scheduled
injuries.” These include such areas as the spine, brain, lungs and mental
function. The method for calculating awards for non-scheduled injuries can be
found at C.R.S. 8-42-108 (8) (d).
Non-scheduled awards are determined by multiplying the following four
factors: 1) the medical impairment rating assigned by the physician, 2) an age
factor which takes into account the injured worker’s age on the date of maximum
medical improvement (see chart at
C.R.S.
8-42-108 (8) (e), 3) a fixed
factor of 400 weeks, and 4) the temporary total disability rate.For example, in a back injury claim, the physician has assigned 10% impairment
as the result of a work related injury. The injured worker (claimant) is fifty
years old and his temporary total disability rate is $200.00 per week. The
award would be calculated as follows:
10% x 1.20 (age
factor for 50 years) x 400 (weeks) x $200 = $9600.00
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- permanent total disability
Permanent total disability means the employee is unable to earn
any wages in the same or other employment. Like temporary total
disability, these benefits are based on two-thirds of the
average weekly wage in effect at the time of injury. Unlike
temporary disability benefits, permanent total disability is
paid for the lifetime of the injured worker (except for injuries
occurring between July 1, 1991, and July 1, 1994.)
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-
prehearing and settlement conferences?
A prehearing
conference is an informal hearing conducted by an administrative law
judge upon request of one of the parties. The judge may order the
parties to attend. A prehearing conference provides an opportunity for
the parties to a claim to meet and discuss issues and concerns about
the case before a judge. The judge may also order the parties to
exchange information, such as employment records, that may assist in
resolving the issues.
A settlement
conference before an administrative law judge may also be requested.
All parties must agree to the conference. The judge will facilitate
discussion and possible resolution of some or all of the issues. In a
settlement conference, the judge must maintain confidentiality of all
conversations or proceedings.
The Division
of Workers' Compensation also is a resource for information regarding
options for arbitration before an administrative law judge. These
conferences may be scheduled in Denver, Boulder, Colorado Springs,
Durango, Fort Collins, Glenwood Springs, Grand Junction, Greeley or
Pueblo. Anyone needing further information about mediation services,
prehearing conferences, settlement conferences or arbitration should
call the Customer Service Unit.
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A hearing is a
formal legal proceeding where an administrative law judge decides what
benefits, if any, must be paid, and decides any other issues. All
parties may present evidence, including documents and sworn testimony
of witnesses. A court reporter makes a record of the hearing. There is
no jury. There is no charge for the hearing. Your failure to attend
may result in an unfavorable decision, a delay in a decision on your
claim, or the dismissal of your claim.
To request a
hearing, you must file an Application for Hearing with the Office of
Administrative Courts and send a copy to the insurance company. You
may request this form by calling the Adjudication Docket. If you
qualify for an expedited hearing, your hearing will be scheduled
within 45 days of the date of the application. All other hearings are
scheduled within 80-100 days. Office of Administrative Courts has two
docket offices, one in Denver and one in Grand Junction. You may ask
for a hearing in Denver, Boulder, Colorado Springs, Durango, Fort
Collins, Glenwood Springs, Grand Junction, Greeley or Pueblo. Call the
Office of Administrative Courts docket section for current information
on locations.
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