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How to Fight Claims of Workers’ Compensation Fraud

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Archive: Aug 2015

How to Fight Claims of Workers’ Compensation Fraud

At DiMarco, Araujo, and Montevideo, we want to make sure all our clients get the chance to be heard and obtain a fair deal. It takes experience, however, to know whether you’re getting a fair deal or not. Workers’ compensation cases are a good example. Many people need workers’ compensation but are afraid they’ll be accused of fraud, or that their employer or insurance companies will deal with them fraudulently. The DAM firm would like to clear up some myths regarding workers’ comp fraud.

Know the Facts

Workers’ comp fraud often happens because employers and their workers don’t know how compensation is supposed to play out. For example, the employer’s work is not done once he or she pays a worker’s comp claim. The employer must help his or her worker return to work if at all possible.

Studies show that 86% of employers have a “return to work” program, which helps ensure employees can return to their jobs at 100% pay after recovering from injuries. This is in comparison to staying on disability benefits, wherein an employee usually receives only 50-70% of normal pay. Many companies, especially smaller ones, cannot afford a return to work program, though. These companies are not committing fraud, but are likely to be accused of fraud if they don’t make some effort to help employees return to work.

Another myth workers and employers often believe is that workers’ comp medical reports are inaccurate. This often comes from bad experiences with physicians. Many physicians sign on with insurance companies to augment private practice income but hesitate to spend money on expensive equipment or diagnostic tests. Therefore, some of these physicians are more likely to treat serious injuries with ever-increasing doses of pain medication, conclude that patients are malingering, or send patients with real injuries to mental health professionals, claiming “you’re just stressed.”

For every careless physician out there, several exist who build trust with patients and file accurate reports using current medical protocol and literature. Such literature includes the AMA Guides and other regularly updated reference materials. Physicians can’t use these to “rate” impairments or say specifically when an employee can return to work; every injury and patient is different. However, they can make educated diagnoses that keep employers and their workers from being cheated out of recovery time, work hours, and wages.

Finally, some employers mistakenly believe technology will solve all workers’ comp problems. For example, it seems logical to think warehouse workers won’t slip and fall as often or get body parts caught in machines if machine and vehicle movement is computerized. Similarly, it would seem that driverless vehicles would drastically reduce or eliminate work-related traffic accidents. The truth is, however, badly used technology can cause as many injuries as traditional employment hazards. They may simply be different types of injuries.

For instance, if everything in a workplace becomes computerized, employers might see a drastic increase in back, neck, and shoulder injuries and related disabilities. If vehicles become driverless, accident rates might go up because the car itself cannot “pay attention” to the road and react to adverse conditions the way a person can. This isn’t to say businesses can’t benefit from technology, but to avoid fraud and increased claims, they should use technology wisely. Business owners should ask themselves what issues they need to solve and whether technology will do the job in the long run. If so, the technology should only be used in areas where it’s most needed.

Workers’ compensation claims can be complex. Have an experienced middle-man between you and the insurance companies. Contact the skilled attorneys at DiMarco, Araujo, and Montevideo today.

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The Most Overlooked Industrial Injuries and Hazards

Without knowledge of what to avoid and how to protect yourself, almost any job can be dangerous. The attorneys at DiMarco, Araujo, and Montevideo see Orange County residents with work injuries every day. The better you know what hazards might crop up at work, the more the DAM Law Firm can help you avoid injury.

Slips and Falls

Slips and falls are often overlooked because they’re so common. Most of them don’t result in workers’ compensation cases, but some are severe enough to warrant worker’s comp and temporary absence from work. In extreme cases, slips and falls can result in permanent disability and job loss.

Workers whose jobs involve high elevations are especially at risk. These include construction workers, warehouse employees, cable installers, and electricians. However, plenty of employees slip or fall without being on a high level. Workers should be vigilant if their jobs involve liquids or chemicals, as these can easily spill on the floor and cause falls. Additionally, employees should make sure they always wear appropriate shoes to work and watch out for potential obstructions.

Muscle Strain, Tearing, Sprains, or Broken Bones

Again, these injuries are so common in the workforce so they aren’t seen as serious. They can become serious quickly, though, especially for middle-aged or senior employees. A variety of jobs can cause muscle strain – even desk jobs. Sitting at a computer for several hours a day may cause back and neck strains, pulls, or tears, especially if the worker doesn’t have good posture.

Any job involving heavy lifting puts employees at risks for tears and sprains, particularly in the lower back, shoulders, and upper body. Broken bones are common in jobs involving carrying heavy loads from one level to the next or from overusing one group of muscles. For example, people who work in landscaping or construction often overuse back muscles when lifting or digging. Workers should check their posture often, follow safety guidelines when lifting, and be cognizant of the weight they carry.

Traffic Accidents

People in the heavy haul or transportation industries are at particular risk for car accidents, which can result in severe physical injuries and emotional distress. The best way employees in Orange County can protect themselves is by being cognizant of statistics and laws. For instance, California’s traffic fatality rates increased 1.5% in 2012, and motorcycle fatalities increased 4.6%.

To stay safe on the road, employees should never use cell phones, text, or email while driving. Employees should not travel for work with a child or teen in the vehicle, and they should always obey seat belt laws. Employees should never drink or use drugs on the job; 29% of the fatal car crashes occurring in 2010 alone involved a drunk driver.

Being Caught in a Machine

Machine-based jobs are some of the most essential in our entire economy. Construction, heavy hauling, demolition, auto repair, and dozens of other industries all use heavy machinery for several tasks. Unfortunately, this puts more workers at risk for permanent and severe injuries from machines. Workers can have digits or entire hands or feet pulled into a machine by accident, or machines can run them over on job sites.

Workers who don’t wear safety equipment or leave their machines unattended are more likely to be killed because of a machine or heavy vehicle. Every employee who works with heavy vehicles or machinery should be fully licensed before entering the field and be tested periodically throughout their careers. Additionally, machines should never be left unattended, and workers should always wear proper safety gear around machinery. Employees working with machinery should undergo periodic drug testing, and no one under the influence of drugs or alcohol should operate machinery.

Don’t face a workers’ compensation injury on your own. Between doctors and insurance companies, you need an experienced voice that understands the legality of your situation. Contact one of the experienced attorneys at DiMarco, Araujo, and Montevideo today.

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How to Avoid Conflict With Workers’ Compensation Doctors

At DiMarco, Araujo, and Montevideo, we’ve seen plenty of workers’ compensation cases. Our attorneys and staff are all trained to deal with every aspect of a workers’ compensation case, including how to avoid conflict with your physician. If conflict with your physician is keeping you from obtaining compensation or negatively influencing how much you get, there are ways to alleviate the situation or avoid conflict altogether.

Conflicts Related to Physician Certification

Most states allow your own doctor to treat you for work-related injuries, though the nature of your insurance claim depends on the doctors your insurance company approves. Many of these doctors don’t have specializations in surgery, orthopedics, or other areas that would allow them to net the income they want from private practice alone. Thus, they work for insurance companies to supplement their incomes and may get a reputation for being “on the fringe” or less qualified than other physicians.

This isn’t always true, but in some cases doctors do take shortcuts. For example, some physicians may not use CAT scans or MRIs to diagnose a worker’s comp injury because that means the insurance company would have to spend its money on diagnostics. Some doctors don’t have access to advanced equipment, don’t keep up with medical literature, or hesitate to spend money on equipment and diagnostics.

If you suspect your physician is treating you with pain medication when you truly need advanced tests, seek a second opinion as soon as possible. If you can, wait 30 days after the initial claim, when you’ll be allowed an exam from any physician, whether or not he or she is on your insurance company’s approved list. Remember too that if your own doctor is on the list, you can seek treatment from him or her. Do so when possible, especially if you have built trust with this physician.

Being Labeled a Malingerer

To malinger is to fabricate illness or injury to avoid work. Ideally, no physician would accuse his or her patient of this, but some do so to remain on insurance companies’ approved list. This is often not malicious; again, these doctors are seeking a paycheck and often, ways to augment their earnings in a shaky economy. Other times, doctors run all the tests they should but can’t pinpoint the source of pain or discomfort.

Do not be afraid to push your doctor. If the prescribed medication isn’t working or if you think a scan or other test is needed, speak up. Additionally, don’t settle for increased medication dosages. Many pain pills can become addictive, so ask your doctor about alternatives to medication, such as advanced tests. If a worker’s comp injury is severe enough for surgery, your insurance company should point you to available approved surgeons.

Questionable Decisions

Workers’ comp injuries are all different, and every employee will be affected differently. Choose a physician who has experience treating workers’ comp injuries and who treats you as an individual. It’s your physician’s job to determine when you can return to work and what duties you can perform, as well as whether any of your injuries will cause permanent disabilities or restrictions.

To do this, your physician will need to give you several thorough exams depending on how long you’re out of work. If you return to work on doctors’ orders and are re-injured, or if you believe your physician made a questionable decision, there are several things you can do.

Seek a second opinion – again, after 30 days you aren’t obligated to stick to your insurance company’s approved list. Speak to your supervisor; he or she can lighten your duties or recommend more recovery time. Finally, speak to your insurance company and hire an attorney if necessary.

The attorneys at DiMarco, Araujo, and Montevideo want you to find a physician you’re comfortable with, not someone in the pocket of an insurance company. Contact one of our experienced attorneys to explain your rights to physicians

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