Let’s assume that your adjuster has offered you a permanent partial disability award (PPD award) based on the rating evaluation that was scheduled by the insurer with either a doctor assigned by DIR from the rotating list, or with a rating doctor you and the insurer agreed to use. Let’s also assume that you’ve asked a knowledgeable person, usually a workers’ compensation attorney, whether the percentage offered appears correct under the AMA Guides criteria, and that you are encouraged to get a second rating. (Please don’t skip getting a good review of the rating report before you decide to spend at least $673 for a second rating evaluation.) Here’s how to obtain that second rating evaluation if you don’t have an attorney helping you:
1. File an appeal
The insurer should include a Request for Hearing form for you to appeal the PPD offer. In order to challenge the first percentage offered, you must file this form with the Department of Administration Hearings Division within 70 days. Even if you cannot complete getting a second rating within 70 days, you must file this appeal form on time. You can always request a continuance of the hearing date if you need more time to get the second rating. Late filing of the appeal form will not be excused because you can’t afford a second rating right now.
2. Ask DIR to assign a second rating doctor
Complete the form used to request the name of a second rating doctor and send it to DIR. Click here for the correct form. If you don’t schedule with a doctor assigned by DIR from DIR’s rotating list, the hearings or appeals officer cannot adopt the percentage found by this second rating doctor.
3. Schedule the second rating and pay for it
You will need to obtain a complete copy of your medical records from your insurer or from each of your treating doctors to send to the second rating doctor before the date of your scheduled evaluation. (Doctors can charge up to $.60 a page for your records.) Some rating doctors only perform evaluations once a month, so be prepared to attend when the rating doctor can fit you into his schedule. You must contact the rating doctor to get yourself scheduled, and you must pay the doctor before your evaluation at the rate set by DIR. Effective 02/01/11, the cost of a rating for one or two accepted body parts is $673.12.
4. Provide a copy of the second rating to the insurer
The second rating doctor should send you a copy of his or her report within two weeks of your evaluation. If the second rating doctor finds a higher percentage, send a copy of the report to your adjuster and ask whether the adjuster will offer the higher percentage. If not, then you will proceed with the appeal you have already filed with the Hearings Division. If the second rating doctor does not find a higher percentage, or finds a lower percentage, then simply write to the Hearings Division and withdraw your appeal. Then, accept the first percentage offered. You are not obligated to show the report with the lower percentage to the insurer.
5. Attend the hearing on the rating issue
If the adjuster responds that the insurer intends to stick by the first, lower percentage, you will need to argue the issue to the hearings officer, and perhaps later, to an appeals officer. Have a copy of the second rater’s report to give to the hearings officer, and make sure you either attend the hearing in person or by telephone. Also have a copy of the bill showing what you paid for the second rating so that you may request reimbursement if the hearings officer agrees with the second rating. Finally, attach the form from DIR showing that the second rating doctor was assigned from the rotating list by DIR.
6. File any necessary additional appeals
The hearings officer may or may not find that the second rating is more accurate. The insurer might convince the hearings officer that the first percentage is correct. Many times the hearings officer will order the insurer to pay for a third rating evaluation. The insurer is not required to accept the findings of the third rater, and can decide again to only offer the percentage found by the first rating doctor. The injured worker then needs to file another appeal. Or, if the hearing officer orders the insurer to pay the higher percentage found by the second rating doctor, the insurer may file an appeal to the next level, the appeals officer level.
7. Be persistent
Unfortunately, contesting a low PPD offer can take time. The insurers know that most injured workers will give up quickly because they need a lump sum payment now. (An injured worker cannot accept a PPD award in a lump sum if they want to appeal the percentage offered.) Many injured workers don’t have the $673 to pay for a second rating evaluation. Before deciding it is not worth fighting, however, an injured worker who thinks the PPD offered is not right should ask for a free consultation with an attorney. Some attorneys are willing to advance the cost of a second rating evaluation if the attorney thinks it is highly likely that a second rating will result in a higher percentage.