Why Legal Representation Is Important In An Ohio Workers Compensation Claim

by Dean Pavick on August 30, 2012

Twenty-first century internet access to Ohio workers compensation documents, information and forms has given injured workers powerful tools to assist them in processing their workers compensation claims. No longer does the claimant generally have to go down to the local BWC office and file a claim application, personally file documents or review their paper claim file.Some of the mystery and time consuming activities surrounding a workers compensation claim have been reduced by modern technology. As a result, many injured workers look at their claim as a fairly simple “do-it-yourself” project.If the claimant has a question he/she can call the assigned BWC claims representative , similar to calling customer service at a bank or  technical support for a computer question.The injured worker’s treating physician can download and file numerous forms with the BWC.Many First Report of Injury forms(claim applications) are filed by healthcare providers such as hospitals and doctors’ offices. If the injured worker suffers a very minor injury(i.e. non-infected cuts, scrapes, bruises or a simple muscle strain which quickly heals) and it is obvious to the BWC and employer that this is a work-related injury, then the claims process and payments for appropriately related treatments should be fairly smooth and uneventful.

Most Employers Have Representation

If Ohio workers compensation claims are  overall” so simple”, why do most Ohio employers have service organizations and/or law firms representing them? State-fund employers(BWC pays for treatments and compensation) realize that workers compensation claims can evolve into complex claims which may have a significant impact on their future premium payments to the BWC. Self-insured employers must directly pay for treatments and compensation in a claim.Most employers want to take every possible step to avoid major cost exposure in a workers compensation claim. Adversarial actions and proceedings can develop at any stage of a claim.

The BWC Is Basically Designed to Reduce Cost

Your local banks and auto dealerships are glad to have and keep you as a customer. After all, they have a lot of competition ready to grab off customers if they stumble or alienate the customers.The BWC, however, is a state run monopoly. It has no competition. Injured workers cannot “shop around” for a better “deal”.The state run system is totally supported by Ohio employers and by BWC investments. High costs in workers compensation claims ultimately drive up employers’ premiums.If premium costs become too high, employers may reduce their payrolls(lay off employees/go out of business)or even leave Ohio.The BWC wants to keep employers happy.They permit state fund employers to join groups to reduce premium costs. If an employer exceeds the expected costs and losses of the group,the employer can be kicked out of the group which drives up that employer’s premiums for several years. Employers will thus take all necessary action in employees’ claims to prevent being kicked out of the group.An Ohio law passed in 1993 allows for privatization of the management of medical care by managed care organizations(MCOs)in state fund claims(most claims). MCOs are for-profit private companies.An employer chooses its MCO during open enrollment season.There is competition among MCOs to sign up employers. Employers are provided with “report cards” on all MCOs.Most employers look for an MCO which reduces medical costs more than other MCOs. Typical cost reduction is achieved by denying,reducing  or terminating treatments,denying diagnostic tests or denying requests for surgery.Certain guidelines(i.e. ODG, Miller Criteria,Diagnosis Determination,Mercy)are used by MCOs and the BWC to restrict treatments particularly after the injury claim has reached early maturity.The BWC also often uses extremely conservative doctors to review claim requests for treatments, additional allowances or disability compensation payments.If the BWC doctor disagrees with the treating physician, the BWC sends the claim to the Industrial Commission for a hearing.

The BWC  annual fiscal reports reveal the BWC efforts to control claims costs. For example,in the Fiscal Year 2012 Report the BWC boasts how various implemented programs have reduced or leveled off employers’ costs by controlling and reducing overall workers compensation costs for medical care and compensation payments. The BWC annual report also shows that the BWC has been paying less money for settlements.Obviously, weeding out waste,fraud and abuse in the system is important. A more efficient system is also important.However, many injured workers and their doctors have been caught up in these so called cost saving measures. A number of doctors no longer want to become involved in the workers compensation system. These actions by the BWC do not mean that most assigned claims representatives at the lower levels are not well meaning in assisting the injured worker.However, they do answer to higher authorities and also usually rely upon the opinions of ultra conservative BWC and MCO doctors. Furthermore, the assigned claims representative, while knowledgeable, is not an attorney and therefore cannot provide legal advice or fully understand the legal implications of all legal issues in a claim.

Justice Delayed is Justice Denied

All types of legal issues can develop in a claim resulting in administrative hearings and possible court litigation which can overwhelm the injured worker and delay treatments and payments.. A workers compensation claim can quickly develop into an adversarial process during any stage of the claim.Unfortunately, it has been our experience that many injured workers do no not contact us until the wheels start falling off in their claim. Often, after a claim has been initially allowed, the injured worker is lulled into a false sense of security that he/she is fully capable of handling the claim by filling out and filing simple forms,relying upon the BWC claims representative,relying on their doctor’s office or an individual from the MCO, or assuming that the employer will continue to cooperate.However,even the filing of a so-called simple form by the injured worker or the doctor’s office can harbor all types of potential legal land mines which can trigger denials, appeals,hearings,delays and even potentially “blow up” the claim. Your doctor is not a lawyer. I have never seen a doctor or a BWC claims representative represent an injured worker at an Industrial Commission hearing or in court.An experienced Ohio workers compensation attorney can help the injured worker navigate the potentially hazardous world of the workers compensation system. There can be legal issues of causal relationships,substantial aggravation of pre-existing conditions, extent of disability issues, overcoming guidelines,dealing with adverse evidence and developing evidentiary requirements,meeting burdens of proof and other work-related legal issues. I hear doctors tell their patients: “if only you had come in earlier, we could have more easily treated your condition “or, “the prognosis would probably have been more favorable if you had come in to see me earlier”. Delays in seeking legal advice can make it much more difficult to seek a favorable outcome, and, in certain cases result in a lost cause.

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