Process & Tips
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Any injury you suffer that occurs during the course of and arises out of your employment may entitle you to workers’ compensation benefits and necessary medical treatment. You may also be entitled to benefits for repetitive trauma injuries or occupational diseases. It is incredibly important for injured workers to have an attorney to advocate for their right to benefits under the law, because many insurance companies and employers often refuse or challenge their obligation to pay the full amount of benefits to protect their own bottom lines.
- Length of physical therapy or treatment
- Date of which medical treatment is complete
- Date of which you are able to return to work
The compensation amount for each claim depends on many factors, such as:
- Extent of your injuries, and whether or not the injuries are permanent
- Extent of the medical treatment needed
- Cost of medical treatment needed
- Amount of work and income lost due to injuries
Considering these factors, the exact worth of each case can vary a great deal, but Spaulding & Shaull is prepared to develop your claim to try to obtain the maximum recovery possible for the injury or injuries you’ve suffered.
What Can Worker’s Compensation Do For You?
It can provide reasonably timely care and payment of weekly benefits to an injured worker at the Employer’s (if self-insured) or its Insurance Company’s (if insured) expense. However, the benefits of the system—via the Iowa Workers’ Compensation Act, Chapter 85 of the Iowa Code—is predicated upon a worker’s showing that he or she has in-fact sustained a “work related” injury. The burden of proof in establishing a work-related injury is on the “Claimant”—the injured worker—who must show that his or her injury occurred “in the course of” the employment and “arose out of” the employment. Establishing, medically, that a work-related injury has occurred, does NOT require a showing by the Claimant that the injury in question was 100% caused by (or the sole proximate cause of) the employment. Rather, the worker must present medical evidence that the employment represented a substantial causal, contributing, or aggravating factor in the development of the particular injury.
Iowa is an Employer-Right-to-Choose state. This means that, if the Employer and their workers’ compensation insurance carrier (if applicable) accepts liability/responsibility for an injury being work-related, then they (as opposed to the injured worker) get to direct the care to the medical provider of their choosing. However, the Defendant-employer and insurance carrier are responsible to pay the Claimant mileage at a required statutory rate per mile (which typically fluctuates between 50 and 55 cents per mile)
It is very important that, when treatment recommendations are made by an authorized medical physician, the client do their best to obtain a copy of that recommendation in writing to provide to their employer and also to their attorney. This allows the attorney to send it to the appropriate defendant-representative (likely the workers’ compensation insurance claim adjuster) to request that the recommended treatment be timely authorized and scheduled. If the Defendants fail to timely authorize the recommended treatment, Iowa law affords an injured worker a procedure known as Alternate Medical Care (via Iowa Code Section 85.27), under which the Claimant can file a petition to have a hearing set to litigate the care issue. Note that these alternate medical care proceedings are limited to addressing issues of medical care and treatment only; NOT to addressing issues related to the payment of weekly benefits to an injured worker.
In some circumstances, if it is determined by a Judge via alternate medical care proceeding that the care being provided by Defendants is not “reasonable” (e.g. is not being provided promptly or is not reasonably suited to treat the employee without undue inconvenience), the Defendants can actually lose control of the Claimant’s care. In those instances, Defendants can actually be ordered to pay for care that is of the Claimant’s choosing.
In many cases, the Defendant-Employer and Insurance Company do NOT accept an injured worker’s claim as being “work-related” and instead formally deny compensability (liability/responsibility) for the Claimant’s injuries. In those instances, the Defendants waive their “authorization defenses” (their right to assert that the Claimant did not have their authority/permission to receive the treatment at issue). Rather, the Claimant is free to treat on his or her own accord with providers of their choosing, but at his or her own expense (hopefully through health insurance, which is obligated to pay for the care under Iowa law once a formal denial of the claim as work-related has been issued). The Claimant can, in turn, seek reimbursement for these medical expenses (via settlement resolution or favorable decision from of an administrative law judge) if he or she can establish (usually through the favorable opinion of one or more physicians selected by the Claimant) that the need for the treatment was indeed due to a “work related” injury.
When an injured worker is restricted from working for more than three (3) days, he or she is entitled to healing period benefits from that point up until the first of one of the following: he or she has returned to work; significant medical improvement is not anticipated (MMI has been reached- addressed below); or he or she is capable of returning to substantially similar work. The first three days (the three-day waiting period) is paid to the injured worker once he or she is off of work for more than fourteen (14) days.
“Maximum medical improvement” (MMI) represents an important point in an injured worker’s case. This is the juncture at which one or more physicians have determined that the injured worker’s recovery has plateaued. This is not to say that he or she is as good as they were prior to injury, nor is it to say that the Claimant will not require some continuing, maintenance-type treatment in the future (e.g. future injections, ongoing prescription medications, etc.). Rather, it is an acknowledgment that, within a reasonable degree of medical certainty, the injured worker is more likely than not as good as they are going to get.
At this point in a case where defendants have accepted the Claimant’s injuries as work-related, the Defendants have an affirmative duty to investigate (with an employer-selected physician) whether or not the Claimant has sustained any permanent functional impairment. This is a doctor-assigned number in the form of a percentage, which the physician renders while utilizing the AMA Guides, 5th Edition, as adopted by the Iowa Administrative Code.
The assignment of this rating by an employer-selected physician, in turn, triggers the Claimant’s right to undergo an “independent medical examination” (IME) (pursuant to Iowa Code Section 85.39) if he or she believes the previous rating to be too low. The Claimant gets to select the provider that conducts this independent examination, and the examination is carried out at Defendant’s expense.
Workers’ compensation in Iowa compensates an injured worker based upon the particular body part injured. Injuries are classified as either scheduled member or body as a whole. Injuries to a scheduled member are based upon a percentage of functional impairment. This percentage of functional impairment is assigned by a medical doctor once an injured worker’s medical recovery has plateaued—known as the point of “maximum medical improvement” (MMI). This percentage is then multiplied by the number of weeks assigned for the total loss of that particular body part under Iowa’s statutory schedule (See Chart Below).
For example: A person that lost their entire hand in an industrial accident would be entitled to 190 weeks of benefits based upon the statutory schedule; whereas, an injured worker who was assigned a 10% permanent functional impairment to his or her hand would be entitled to 19 weeks of benefits (10% of 190 weeks) based on the schedule.
|Loss of thumb
|Loss of first finger
|Loss of second finger
|Loss of third finger
|Loss of fourth finger
|Loss of hand
|Loss of arm
|Loss of great toe
|Loss of any other toe
|Loss of foot
|Loss of leg
|Loss of eye
|Loss of hearing in one ear
|Loss of hearing in both ears
|Permanent disfigurement, face or head
|Body as a whole/industrial disability
The Formal Litigation Process
An injured worker begins the formal litigation process of his or her workers’ compensation claim by filing an Original Notice and Petition with the Iowa Workers’ Compensation Commissioner’s office. Once the employer and its insurance carrier have been served with a copy of the injured worker’s petition, they will file an Answer either admitting or denying liability for the injured worker’s claim. Once the employer and its insurance carrier have filed their Answer, the parties can begin the discovery process. During the discovery process, the Claimant and Defendants can serve written questions – called interrogatories – and requests for production of documents upon each other.
The employer and its insurance carrier will typically ask the injured worker questions regarding the Claimant’s educational and employment history, as well as the Claimant’s medical history. Documents that the Claimant is commonly asked to produce by the employer and its insurance carrier include medical records, bills, and tax returns. The injured worker will commonly ask questions and request documents from the employer and its insurance carrier regarding the Claimant’s earnings history, incident reports created as a result of the subject workplace incident, and a copy of the Claimant’s personnel file.
After this written discovery process is completed by the parties, the next step in the discovery process typically involves the employer and its insurance carrier’s attorney taking the Claimant’s deposition. A deposition is conducted in the presence of a court reporter who records and transcribes the questions and answers posed to the Claimant during his or her deposition. A deposition is sworn testimony (taken under oath) and is treated as if it were given live in court. The Claimant’s attorney may also take the deposition(s) of witnesses to the Claimant’s work-injury, or other representatives of the Claimant’s employer.
Workers’ compensation claims are not set for trial before a jury. Rather, an administrative hearing before a Deputy Workers’ Compensation Commissioner is scheduled, approximately 12-months from the date that the Claimant’s Petition was filed. The administrative hearing is limited to 3-hours of testimony from witnesses, divided equally between the Claimant and the Defendants. The parties submit exhibits at the Hearing, such as the Claimant’s medical records and reports from the Claimant’s treating and evaluating physicians. Additionally, the parties may submit relevant portions of the Claimant’s personnel file with the Defendant employer, such as the Claimant’s job description and attendance records.
After the workers’ compensation hearing has ended, the evidentiary record is closed. The Deputy Commissioner who presided over the workers’ compensation hearing will issue a decision regarding the Claimant’s entitlement to benefits anywhere from 3-12 months after the hearing. Once the decision has been issued, either party may appeal the decision to the Iowa Workers’ Compensation Commissioner who issues an appeal decision. The appeal decision can take 18-24 months for the Commissioner to issue. After the appeal decision has been issued, it can be further appealed to the District Court level, and thereafter, to the Iowa Court of Appeals and Iowa Supreme Court. This can take additional years.
Basic Types of Settlement Resolution
The vast majority of workers’ compensation claims are resolved through settlement prior to the administrative hearing before a deputy workers’ compensation commissioner. There are a number of different types of workers’ compensation settlements, which include: (1) agreement for settlement; (2) compromise settlement; (3) combination settlement; (4) contingent settlement; and (5) full commutation.
Agreement for Settlement: When an agreement for settlement is reached, the injured worker and the Defendants agree that the employee sustained a work-related injury; that the employee is entitled to some amount of weekly benefits; that the employee is entitled to medical care into the future; and that the settlement is subject to review-reopening for three (3) years after the last date weekly compensation was paid to the injured worker.
The benefit of an agreement for settlement to the injured worker is that the Defendants are still responsible for necessary future medical care, and the injured worker has the ability to file a review-reopening proceeding. The benefit of this type of settlement to the injured worker’s employer and insurance carrier is that the Defendants receive a credit for the past benefits paid to the injured worker if he or she sustains a subsequent work-related injury during his or her employment with the defendant employer.
Compromise Settlement: A compromise settlement – the most common type of workers’ compensation settlement – is a full and final settlement of the injured worker’s claim. With this type of settlement, the defendant employer (or its insurance carrier) makes a one-time lump sum payment to the injured worker to close out the injured worker’s claim for a particular injury. The benefit of a compromise settlement to the injured worker is that he or she receives a lump sum payment for the agreed upon amount between the parties, rather than weekly payment of benefits for said amount which could take several months (or even years) for the injured worker to collect in full. The benefit of this type of settlement to the injured worker’s employer and insurance carrier is that it results in a “closed-file” – meaning that the employer and insurance carrier faces no further liability for the injured worker’s future medical care or workers’ compensation weekly benefits after the lump sum has been paid.
Combination Settlement: A combination settlement combines the agreement for settlement and the compromise settlement. With a combination settlement, the employer’s liability for certain portions of the injured worker’s claim are established, and the employer’s liability for other portions of the injured worker’s claim are extinguished. Like a compromise settlement, a combination settlement results in a full and final resolution of the portions of the injured worker’s claim for which the employer’s liability was extinguished. An example of a situation where a combination settlement may be utilized is where an injured worker has a physical injury for which liability is admitted and a psychological injury for which liability is denied.
Contingent Settlement: A contingent settlement hinges on an event that is expected to occur within one year, such as approval of a Medicare set aside trust. If the contingency does not occur, either party can petition the workers’ compensation commissioner to vacate the approval. The contingent settlement becomes final and fully enforceable if no action is taken by either party to vacate the settlement or to extend the time period for approval.
Full Commutation: A full commutation of all remaining benefits owed to an injured worker into the future is paid by the employer or its insurance carrier in one lump sum, discounted payment. A full commutation terminates the injured worker’s right to future medical benefits or to a review-reopening proceeding. An injured worker must file an application for a full commutation to be approved by the workers’ compensation commissioner’s office. An application for a full commutation more commonly occurs after the workers’ compensation commissioner’s office has issued a decision awarding the injured worker weekly benefits to be paid into the future.
What Worker’s Compensation Does Not Do
Unfortunately, the workers’ compensation system was not designed, as a general matter, to make one completely whole, in that it does not compensate for an injured worker’s physical and/or mental pain and suffering or anguish. For this reason, it was also not designed to result in an injured worker becoming a millionaire. Rather, as explained above, its designed-purpose was to provide reasonably quick benefits to an injured worker in the form of medical treatment, weekly healing period benefits while off of work recovering, and, where appropriate (in instances of permanent injuries), weekly permanency and industrial disability benefits for permanent functional impairment and/or loss of future earning capacity.
This give-and-take is referred to as the “quid pro quo” of work comp. In essence, an injured worker is not required to prove that the employer was at fault for his or her work-place injury. Stated alternatively, the injured worker is not required to prove negligence, as would be required in a non-occupational accident or incident of injury. The injured worker must only show that his or her injury occurred in the course of and arose out of the employment. For that reason (and in exchange for not having to meet the additional burden of fault/negligence), an injured worker is not entitled to items of damage such as pain and suffering and emotional distress (that might be afforded upon a showing of fault/negligence to a plaintiff in a non-occupational, district court action for damages). The only exception to this rule—known as the Exclusivity Doctrine of workers’ compensation (that you cannot file suit against your employer in district court for a work-related injury)—are those cases in which the injured worker can prove gross negligence by a co-worker. This is a very high standard/burden to meet in Iowa, and is limited to claims against “co-employees”—not against the employer (or business entity) itself.
The workers’ compensation insurance carrier (and the workers’ compensation system, in general) does not control or dictate your particular employer’s unique employment policies or handbooks. This is because they are unique to each and every employer and are designed to be applied uniformly to all employees with that employer—regardless of whether or not they have sustained an injury. Stated alternatively, these employer policies are independent of the issue of a workers’ compensation carrier insuring/covering for an injury to a worker.
Similarly, any short-term disability and/or long-term disability policy that is offered through your employment is not controlled/dictated by your employer’s workers’ compensation carrier or the workers’ compensation system at large. Rather, these are private insurance policies (which, necessarily, are private contracts) that are dictated by the particular terms contained within that contract of insurance. In fact, oftentimes these policies are issued by a completely different insurance carrier than the workers’ compensation insurance carrier for the employer. Moreover, the policies are typically designed to cover nonoccupational injuries or illnesses, or, at a minimum, injuries that are being handled by the Employer and Workers’ Compensation Carrier as nonoccupational (meaning the injuries are being denied as work-related by work comp).
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