Claims Filing, Understanding the Claims Process, Benefits, and Dispute Resolutio
When you’re injured at work, you must notify your employer IMMEDIATELY.
If your injury occurs over a period of time versus immediately, then you should notify your employer as soon as you’re aware of the injury.
Your employer will then file a workers’ compensation claim with their insurance company, and you should be given a copy of that report.
If your employer does not file a workers’ compensation claim, then you can contact our office (802) 828-2286 and request a Form 5 – Employee’s Notice of Injury and Claim for Compensation [PDF].
If you file a Form 5 you will be required to provide evidence that your injury was as a result of your employment.
This will include medical records and statements from anyone who witnessed the injury.
Understanding the Claim Process
If you are injured at work you should do the following:
1. Tell your employer about your injury as soon as possible. Get the necessary medical care. Tell the doctor that you are there due to a work injury. If you are unable to work you MUST get a WRITTEN doctor’s note.
2. Your employer must report to the Department within 72 hours of receiving notice of your injury if that injury results in medical care or an absence from work. Your employer should give you a copy of the report they file. If your employer does not report your injury you may call the Department at (802) 828-2286 and request a Form 5 to report the injury yourself.
3. Your employer may direct you to a company doctor for your first medical visit. After that visit you may pick your own doctor by filing a Form 8 Change of Health Care Provider. You can obtain a Form 8 from the insurance carrier or from this Department.
If you are working part-time, then you should schedule your medical appointments outside of your work hours. However, if you must go to a medical appointment during work, then your employer cannot withhold wages for the time you miss because of the appointment.
4. Your employer’s insurance company has 21 days from the date that employer received notice of your injury to investigate your claim and determine if your injury is covered. The insurance adjuster should contact you for information about your injury. The insurance company will send you a Form 7 Medical Authorization so they can access your medical records related to the injury. Return the Form 7 Medical Authorization to the insurance company promptly. This investigation process will go faster and smoother if you provide your employer information about your injury.
5. You must keep your employer’s insurance company aware of any medical appointments and any contact information changes.
6. If you do not hear from your employer’s insurance carrier feel free to contact this office at (802) 828-2286.
Workers’ Compensation Benefits
Depending upon the seriousness of your injury and whether or not it affects your ability to work, you may be entitled to one or more workers’ compensation benefits including:
· Medical benefits
· Wage replacement benefits (known as temporary disability benefits)
· Permanency benefits
· Vocational rehabilitation
· Death benefits – these may also be available to a worker’s spouse or family members if the worker dies from a work injury
Medical Benefits
Your employer’s workers’ compensation insurance should pay for all reasonable and necessary medical services and supplies related to an on-the-job injury. In some cases, this may include not only coverage for doctor visits and hospital treatment, but also coverage for physical therapy, medication, chiropractic treatment and psychological counseling.
Temporary Disability
If you are unable to work at all during your recovery from a work-related injury, then you will be provided with weekly wage replacement compensation, called temporary, total disability (TTD) compensation. If your doctor releases you to part-time work or light duty work while you are recovering, then you may be entitled to temporary, partial disability (TPD) compensation.
To obtain TTD benefits, you must be disabled from work 4 days or more due to your injury.
Your TTD benefits are approximately two-thirds of your usual wage.
You receive an additional $10 per week for each of your dependent children.
If your doctor releases you to part-time work, you receive partial compensation, two-thirds the difference between your full and part-time pay.
What if I have dependents?
In addition to any temporary disability benefits, you will be provided a small supplement for each of your dependent children. Your employer’s insurance adjuster should provide you with a copy of a Form 10 to report your dependents and also any wages you may have lost from a second or third job as a result of your injury.
If not, you may download a Form 10 here or by contacting our office at (802) 828-2286.
Permanent Impairment Benefits
If you are left with a permanent impairment following your recovery, you may receive additional compensation related to loss of function once your temporary disability compensation ends. The law provides a schedule from which these benefits are calculated. You will receive periodic payments unless a lump sum request is approved by the Workers’ Compensation and Safety Division.
Vocational Rehabilitation Benefits
If your injury prevents you from returning to employment that you have previous training or experience for, you may be eligible for Vocational Rehabilitation services. This may include training, job placement or on-the-job training to help you return to suitable employment.
Can my benefits be discontinued?
Yes, any of your benefits can be discontinued provided the adjuster files a properly supported Form 27 with you and the Department. The insurance carrier can stop payments if you return to work, are medically released to return to work, reach maximum medical improvement (MMI) (a plateau in your recovery), or do not cooperate in your claim.
If you get medical benefits for a time, these benefits can be discontinued if there is medical evidence that you no longer need treatment or your treatment is not necessary and reasonably related to your injury. The insurance carrier must provide evidence from your own medical doctor, from your medical records or from an Independent Medical Examination (IME) to support discontinuance of your medical benefits.
You may request an informal conference to challenge a discontinuance of benefits by filing a Form 6 request for hearing.
Dispute Resolution
Disputes may include, but are not limited to:
· Compensability of a claim, in whole or in part;
· Calculation of the compensation rate;
· Correct impairment;
· Reasonableness and necessity of medical treatment; and
· Vocational rehabilitation.
The dispute resolution process begins upon receipt of a Notice and Application for Hearing (also called Form 6), or comparable written notice, from the injured worker or the insurance adjuster, or their legal representatives, and in some instances, a medical provider.
Purpose of the Informal Resolution
The purpose of an informal conference is to identify and discuss disputed issues in an attempt to resolve the dispute(s). It’s an opportunity for the parties to ensure they have complete information, clear up any misunderstandings or miscommunication involving factual issues and allow the parties to identify the specific evidence they are relying on to support their respective positions.
Evidence may include, but is not limited to, specific medical records, a medical opinion, witness statements, and affidavits. Parties may also reference to specific laws, rules, or prior hearing decisions by the Commissioner or the Vermont Supreme Court that may be applicable and set precedent on the particular issues in dispute.
This office does not request medical records from medical providers or otherwise gather evidence for the parties. It is the responsibility of each party to gather and file with the Department and the opposing party or its representative copies of the medical records and other documents relied upon in the informal resolution process.
Role of the Specialist
The role of the Department Specialist is to review the evidence submitted by the parties and make a determination as to whether the insurer is responsible for payment of workers’ compensation benefits under the Vermont’s Workers’ Compensation Act.
The Specialist will take one or more of the following steps to address a hearing request based on the evidence presented and the information already on file with the Department:
· Schedule an informal telephone conference;
· Request that additional information be submitted before scheduling an informal telephone conference;
· Make a recommendation to the insurer to pay benefits and set a deadline for response;
· Issue an Interim Order requiring an insurer to pay benefits at any time before, during or after an informal conference.
· Schedule additional conferences if it appears additional conferences may lead to the resolution of the dispute;
· Send the parties a letter briefly outlining the results of the conference and the Specialist’s decision based on the information that was available at the time that each conference is held, which may include upholding the insurer’s position or issuing an Interim Order requiring payment of benefits in whole or in part.
· Refer the matter to the formal hearing docket if it is apparent that no progress towards resolution is likely at the informal level.
Representation
The parties are not required to be represented during the informal resolution process but may choose to be. It is entirely the decision of the injured worker or the insurance adjuster whether to retain counsel to represent their interests.
The Department does not represent the injured worker, the employer or the insurer.
Difference between the Informal and Formal Process
The informal conference is conducted over the telephone and is not recorded. The formal hearing requires in-person attendance of the parties or their legal representatives. During the informal conference, the parties are not placed under oath and verbal testimony of witnesses and medical experts is not taken. The formal hearing is recorded, the parties’ testimony is under oath, and witnesses and experts testify and are cross-examined.