What To Do If a Body Part Is Not Accepted on Your Nevada Claim


By Jason Weinstock on February 16, 2010
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Many times  an injured worker does not realize that other parts of the body have been  injured when he or she is first getting medical care for the most obvious injury and when completing the C-4 claim form.  Directly above the signature line on the C-4 Claim for Compensation form is a boxed area for the injured worker to write what parts of the body were injured.  When the claims adjuster receives the C-4 form, the adjuster notes what the employee says was injured with  what the doctor writes as the diagnosed and treated  injury on the lower portion of the C-4 form. 

The adjuster then  uses the information on the C-4 form, as well as any  available medical records, when sending the  Notice of Claim Acceptance letter.  Most adjusters will state exactly what body parts are accepted on that Notice of Claim Acceptance.  At the bottom of that letter, the adjuster will also tell the injured worker that he or she has 70 days to request a hearing if there is something he or she disagrees with in the letter.  The majority of injured workers who receive a Notice of Claim Acceptance do not carefully read that letter, and do not take any action to make sure that the adjuster sends another letter including any body parts that are not mentioned in the Notice of Claim Acceptance.

Problems arise when the injured worker tries to get medical treatment for a body part that is not specifically mentioned in the Notice of Claim Acceptance.   Adjusters often deny requests for necessary treatment to an additional or different body part weeks or months after the claim is accepted when diagnostic testing reveals an injury to an additional body part.  

Fortunately, the last legislature recognized that injured workers are being denied necessary medical treatment by adjusters taking advantage of injured workers who do not file appeals from a Notice of Claim Acceptance letter that lists accepted body parts.  A recent amendment to NRS 616C.065, effective October 1, 2009,  states that the failure of the insurer to indicate the acceptance or denial of a claim for a part of the body or condition does not constitute a denial or acceptance thereof.   That means that if an injured worker specifically requests that an additional or different body part be included on the claim, the insurer  must make a new determination and give appeal rights again.  The insurer cannot simply state that  a Notice of Claim Acceptance letter was sent and the appeal time to contest the listed body parts has run.

 Even with the recent amendment to NRS 616C.065, an injured worker should immediately request that a Notice of Claim Acceptance letter be corrected if all affected body parts are not listed.  If the injured worker does not realize that additional body parts were injured until much later, then the injured worker should request in writing that the adjuster include the body part.  If the adjuster fails to take action, the injured worker may file an appeal after 30 days from sending his written request to the adjuster.  If the adjuster denies the request to include another body part, the injured worker should promptly file an appeal on the form provided with the denial letter.

 

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