One of the questions I receive from my clients is, “why do worker’s compensation attorneys appeal the initial claim acceptance letter and subsequent scope determinations?” This is a good question and often doesn’t make sense to injured workers’ when they are receiving the treatment they want or need.
One of the reasons attorney’s appeal the initial claim acceptance letter is because the law requires the workers’ compensation insurance adjuster to accept or deny the claim within 30 days. This means that adjusters are issuing an acceptance letter often based off the C-4 form and the diagnosis listed therein. These C-4 forms are normally completed at a Concentra Medical Center, CareNow Urgent care, hospital, or some other urgent care. The doctors at these urgent cares and hospital emergency rooms are often general practitioners and not specialists. It is rare that you see specific diagnoses on a C-4 form. More common diagnoses are sprains or strains of the injured body part.
“Look, I am getting treatment for my back, why do I care that they accepted it for a lumbar strain?” Ok, the adjuster accepted your claim for a lumbar sprain 30 days after you completed the C-4 form. That’s great! You can now start treating for your industrial injury and even request to see an orthopedic specialist. This leads to another reason why workers’ compensation attorneys appeal the initial claim acceptance letter. Fast forward, now you are treating with the orthopedic specialist and they say you have herniation at L4-5 and radiculopathy (numbness and tingling down your leg caused by a nerve impingement from the herniation). The fact that the herniation and radiculopathy were not included in the claim acceptance could impact your permanent partial disability evaluation, impairment percentage and your future reopening rights.
“How,” you ask. The claim acceptance letter states what it is that the workers’ compensation insurance company is accepting liability for. Although a rating doctor is supposed to rate you based on your medical records and physical examination it isn’t unusual for an insurance company to contest a permanent partial disability evaluation because the doctor gave you a percentage for a diagnosis that the insurance company never accepted. For example, a diagnosis of unverified radiculopathy can be a 5-8% impairment percentage, where as an argument can be made that acceptance with out the radiculopathy (just a strain) would only warrant a 0%.
Further, let’s say your claim was only accepted for a lumbar strain (even though you have a herniation at L4-5) and two years after your claim was closed a doctor says your condition worsened and you now need surgery. Adjusters love to make the argument that the claim was only accepted for the strain and deny the future surgery as new injury.
In short, not appealing the initial claim acceptance letter can forfeit your right to add additional body parts and diagnoses to the industrial claim and effect your settlement, treatment, reopening rights.