WHAT QUALFIES AS A WORK-RELATED INJURY?
An injury arising out of and in the course of employment is typically considered work-related. If you are at work, performing a work-related activity, and experience a change in your condition, you have likely sustained a work-related injury. Medical conditions caused, directly or indirectly, by your work activities, circumstances, or an accident/incident, are an “injury”. If the performance of your work duties causes a current or pre-existing medical condition to worsen, the change in medical condition may also be considered an “injury”.
Moreover, Arizona is a No-Fault System. Fault is not considered in determining whether the employee sustained a work-related injury. If an employee causes his or her own injury, the claim will not be denied on that basis. Furthermore, medical and disability benefits are neither increased nor decreased based on fault.
Types of work-related injuries vary: they may include hernias, bulging or herniated discs in the spine; tendon and ligament tears involving the shoulder, hip or knee joints; sprains, and fractures involving the upper and lower extremities; or hearing and vision impairment. Industrial injuries may also involve occupational diseases as such a vocal cord dysfunction, asthma, or latex allergy. An injury may be a mental illness, or an emotional condition related to the effects of your employment.
The onset of symptoms involving work-related injuries may be immediate, such as an acute onset of low back pain when lifting a heavy object. However, not all work injuries necessarily cause the onset of immediate pain. Injuries arising out of repetitive or cumulative trauma generally do not manifest immediate symptoms. Because of the repetitive nature of the work activities, or exposure to the environmental conditions, symptoms may develop over time. Injuries involving joints, generally starting with soreness or achiness which then may progress to pain, stiffness, numbness and weakness of the extremity. Hearing loss may not be noticeable until years of continued exposure.
HOW DO I OPEN A WORKERS’ COMPENSATION CLAIM IN ARIZONA?
You can initiate a workers’ compensation claim by reporting to your injury occurred at work to the first medical provider you see for your injury. The medical provider is required under Arizona law to file a “Worker’s and Physician’s Report of Injury” form with the Industrial Commission of AZ (“ICA”). The ICA is a state agency where the workers’ compensation claims are filed by the injured workers and their medical providers. The “Workers’ and Physicians Report of Injury” form is known at the ICA as Form 102. You will complete the top half of the form and your medical provider will complete the bottom half of the form. The medical provider will then file the form with the ICA. Please make sure you receive a copy of the Form 102 before you leave the medical provider for verifications purposes. It is advisable to contact the Industrial Commission of Arizona (602) 542-4661 within two (2) weeks to make sure your medical provider file the “Workers’ and Physicians Report of Injury” with the Industrial Commission. If the Form was not filed with the ICA, your workers’ compensation claim will not be opened by the state agency.
When you are contacting the Industrial Commission, please make sure you ask the agency for your Industrial Commission Claim Number, which is assigned to your claim. Your injury claim will be permanently identified by this number at all stages of the claim proceedings at the Industrial Commission of AZ.
You can also open a workers’ compensation claim on your own by filing a “Workers’ Report of Injury” with the Industrial Commission of AZ. The “Workers’ Report of Injury” form is known at the ICA as Form 407. You can file this form on the Industrial Commission of AZ website by clicking the link: https://www.azica.gov/claims-workers-report-injury . You can also file Form 407 at the Industrial Commission of AZ, 800 W. Washington St., Phoenix, AZ 85007. Please make sure you keep a copy of the Form for verification purposes.
PLEASE BE ADVISED THAT YOUR EMPLOYER and its workers’ compensation insurance company CANNOT OPEN A WORKERS’ COMPENSATION CLAIM FOR YOUR INJURY AT THE INDUSTRIAL COMMISSION OF AZ. Only you and your medical providers can open a claim on your behalf. Do not rely on your Employer and their workers’ compensation insurance company telling you that they will open a claim with the Industrial Commission. They can’t.
As you can see now, it is very important that you report to each medical provider you see for your injury that your injury happened at work!
HOW LONG DO I HAVE TO FILE A WORKERS’ COMPENSATION CLAIM IN ARIZONA?
You must file a claim in writing with the Industrial Commission of Arizona (“ICA”) within ONE (1) YEAR after the injury occurred. The time for filing a claim starts to run when the injury occurs, or when you become aware of the injury or in the exercise of reasonable diligence should know that you suffered a work-related injury. Some injuries may not become apparent to you as work-related within a year. At times a medical provider may not tell you the injury is work related within the year. If that happens to you, do not delay contacting us for help as the time to file a workers’ compensation claim is running.
IMPORTANT! While Arizona Workers’ Compensation Law permits an injured worker to file a claim within 1 year from the date of injury, pursuant to A.R.S. §28-908(E) the injured worker has a duty to report the accident and injury “forthwith” to the employer. In most cases the report is made to the employee’s supervisor or to Human Resources. While immediate reporting is always recommended, it may not always be feasible due to the circumstances. Additionally, some injuries do not manifest themselves immediately. Notwithstanding, an injured worker should report the incident and injuries as soon as possible.
WHAT HAPPENS AFTER A CLAIM IS FILED FOR MY WORK INJURY?
The Industrial Commission of Arizona (“ICA”) will check to see if your Employer has worker’s compensation insurance on the date of your injury. It is mandatory for employers who carry workers’ compensation insurance for employees in Arizona. If your Employer is covered, the ICA will notify the Employer of your workers’ compensation claim with a letter. You will receive a copy of the notification letter. Your Employer and its insurance company have twenty (21) days from the date of the notification letter to accept or deny your claim. The claim is accepted or denied in a Notice of Claim Status issued by the workers’ compensation insurance company.
If the Employer fails to obtain workers’ compensation insurance for its employees, your claim will be handled by the Special Fund/No Insurance Section of the Industrial Commission of Arizona. The Special Fund will contact you for documentation of your status as an employee and your work injury, and then will issue a Notice of Determination Pursuant to A.R.S. Section 23-907(B), accepting or denying your claim. If your claim is accepted, the Special Fund/No Insurance Section will administer your medical and disability benefits just like a workers’ compensation insurance company would on behalf of the insured employer.
WHAT ARE AVAIALBLE MEDICAL BENEFITS FOR MY WORK INJURY?
If your workers’ compensation claim is accepted, you are entitled to medical and disability benefits under Arizona law. You are entitled to reasonable and necessary medical care related at least in part to your work injury. The medical care is typically considered related if it helps to alleviate symptoms and limitations from your injury.
It is very important that you tell the medical provider about the effects of your injury. One way to make sure you do not forget to tell him or her, is to keep a record, or a diary, of your symptoms and limitations. You can record how certain activities make your symptoms worse. Similarly, once your treatment starts, you can record what make your symptoms better.
ACTIVE MEDICAL CARE
Shortly after the work accident, you will likely be entitled to “active” medical care for your work-injury. The “active” care is designed to improve the physical condition of your injury, such as surgery. Once your injury stabilizes, your may be discharged from active care having reached maximum medical improvement (“MMI”). Whether you have reached MMI is determined by a medical provider, whether your treating physician or a physician retained by the workers’ compensation company who will see you in an Independent Medical Examination (“IME”).
SUPPORTIVE MEDICAL CARE
Upon reaching MMI, you may be recommended “supportive” medical care by the examining physician. The “supportive” care is deigned to maintain the status of your injury upon reaching MMI, and typically address your symptoms rather than further change the physical condition of your injury at the time of discharge. It is very important that you use supportive care as otherwise the insurance company will terminate for nonuse.
You may also be eligible for reimbursement of your travel expenses if your physician is not in the same place where you worked or lived at the time of your injury.
NO OUT OF POCKET EXPENSES
All of your bills for treatment necessary and related to your work injury should be paid by the workers’ compensation insurance company. You should not have any out of pocket expenses for treating of your injury.
AM I REQUIRED TO TREAT WITH PHYSICIANS CHOSEN BY MY EMPLOYER AND ITS INSURANCE COMPANY?
You are not required to treat with physicians selected by your Employer and its workers’ compensation carrier beyond a one-time evaluation unless the Employer is self-insured with the right to direct medical care. There are some employers in Arizona who have the right to decide who will be your physician and what medical facility you will be allowed to go to. You can check if your Employer qualifies for this special status at the Industrial Commission of Arizona (“ICA”) website: https://www.azica.gov/divisions/claims-division.
If your Employer does not qualify, you have a right to select your own treating physicians. Please be aware that if you have seen a medical provider sent to by your Employer a second time, you will need to seek permission from the ICA to switch physicians before the insurance company will be responsible for the payment of your medical care.
HOW DO I CHANGE PHYSCIAINS FOR MY WORK-INJURY?
You can change your treating physicians by filing a “Request to Change Doctors” with the Industrial Commission of Arizona (“ICA”), even if the insurance company adjuster denies your informal request. Before you file your request, you will need to obtain the consent of the new physician to accept you as a patient under the workers’ compensation claim. Make sure you check with the physician’s office that they accept workers’ compensation patients as not all physicians do.
If you have not selected your treating physician, your request to switch physicians will typically be approved by the ICA upon you filing a “Request to Change Doctors”. You can find the form on the ICA website: https://www.azica.gov/divisions/claims-division. Even if you have selected your treating physician once before, you may be able to change physicians again provided your situation satisfies certain criteria established by the ICA rules.
It is important to know that if the Ica denies your “Request to Change Doctors”, you have only ten (10) business days from the date of the denial to appeal by filing a “Request for Hearing” with the ICA. If you miss the deadline and the denial becomes final, your treatment with the new physician will not be paid for by the insurance company.
I AM UNABLE TO WORK, AM I ENTITLED TO LOST WAGES?
Whether you are entitled to lost wages depends on your work status as determined by a medical provider. If a physician removes you from work shortly after the injury and places you on a no-work status, you are entitled to receive “Temporary Total Disability”. If you are placed on a “light duty” work status and unable to find work within your physical limitations, you may be entitled to a “Temporary Partial Disability”. The temporary disability benefits are paid based on a portion of your Average Monthly Wage.
Your entitlement to temporary disability benefits largely depend on your physical abilities as determined by the medical provider post injury, as discussed below. If your ability to earn wages is lost on a permanent basis, you also be entitled to permanent disability benefits as well depending on number of factors discussed below.
WHAT IS “AVERAGE MONTHLY WAGE”?
The Average Monthly Wage (“AMW”) is the average amount of money an injured worker earned before the work injury. The AMW is typically set based on the 30-day income immediately before the injury. If the 30-day income does not accurately reflect your average monthly earnings, your AMW may be based on the average monthly earnings up to a year prior to your date of injury.
It is very important for you to make sure your AMW is correctly determined by the Industrial Commission of Arizona. (“ICA”). All your temporary and permanent disability benefits are paid off the AMW amount. If the AMW is set too low, you will receive less compensation. You should carefully review all of the documents received from the ICA and insurance company establishing your AMW. If the AMW is set too low, you will have ninety (90) days from the date the “Notice of Average Monthly Wage” is mailed to appeal by filing a “Request for Hearing” with the ICA. If the notice is not appealed timely, your AMW will become final.
Wages from all of your jobs should be considered together in establishing the AMW, if you have multiple employments. Depending on your occupation, compensation received for room and board, food, etc. can also be included in your AMW.
Monthly wages recognized under the Workers’ Compensation Act are capped. The maximum wage recognized as of January 1, 2018 is $4,625.92 per month. Any monthly income above this wage will not be used to pay compensation benefits. The ICA has set a capped monthly wage for a specific time period, which you can view here: https://www.azica.gov/average-monthly-wage-maximum-history.
WHEN IS TEMPORARY TOTAL DISABILITY PAID?
Temporary total disability (“TTD”) benefits are paid every fourteen (14) days when an injured worker is unable to work because of the injury, as determined by the physician. When the physician places you on a no-work status and you claim is accepted, you are entitled to the TTD benefits. The TTD benefits are paid on the basis of 2/3 of the Average Monthly Wage. An injured worker is typically placed on the no-work status to allow the physician to appropriately diagnose the injury, allow you the time to heal from the injury without risking aggravation or recover from surgery.
WHEN IS TEMPORARY PARTIAL DISABILITY PAID?
Temporary partial disability (“TPD”) benefits are paid every thirty (30) days upon the injured worker being released to light or modified duty, as determined by the physician. The light or modified duty release means that you are not capable of returning to regular duty and should honor the restrictions placed on you by the physician. Once this happens, you will be required to ask your date-of-injury employer to accommodate your light or modified duty. If your Employer cannot make such accommodations, you will be required to apply for light or modified duty work with other employers and list the submitted job applications on a “Monthly Status Report”. Upon submitting the “Monthly Status Report” to the insurance company adjuster, your TPD benefits will be released on the 30th day. The TPD benefits are paid on the basis of 2/3 of the Average Monthly Wage (“AMW”).
Any wages earned on the light or modified duty will be credited against your entitlement to compensation benefits during TPD status. If you earn no wages despite your good faith effort to find light or modified duty employment, you are still due 2/3 of the AMW in TPD benefits. However, many insurance company will assert that the injured worker failed to look for hard enough, or light or modified duty jobs exists based on the opinion of a labor market consultant and then reduce or stop payment of the compensation benefits. This is a tactic used by the insurance companies to force the injured workers to settle for less than what is due. Such scenarios frequently result in litigation before the Industrial Commission judges.
AM I ENTITLED TO PERMANENT DISABLITY?
Whether an injured worker is entitled to a permanent disability depends on a number of factors, such as if the injury results in permanent impairment and permanent work restrictions, the location of the injury, and the effect of the injury on your ability to earn money after the medical discharge.
There are two types of permanent disabilities, scheduled and unscheduled. A scheduled disability will pay a set amount of money for the disability based on the “schedule” established by the Industrial Commission of Arizona (“ICA”). The “schedule” contains a list of the injuries that qualify for a “scheduled” disability. The disability is based on your Average Monthly Wage (“AMW”) and permanent impairment rating as determined by a physician. A set amount is paid without regard to the impact that disability has on your life or ability to return to work in the future. If the work restrictions allow you to return to the date of injury job, your “scheduled” disability will be paid at fifty percent (50%) of the AMW.
If your permanent work restrictions prevent you from returning to the date of injury job, your scheduled disability should be paid at seventy-five percent (75%) of the AMW in
An “unscheduled” disability will pay lifetime benefits, on a monthly basis, provided the injured worker sustained a loss of earning capacity (“LEC”) due to the work injury. If you are able to earn the date of injury wages after the injury, there is no LEC and no disability will be paid even if you sustained a permanent impairment and permanent work restrictions. If you are only capable of earning less wages because of the permanency of your injury, then the disability benefits are based on the fifty-five percent (55%) of the recognized loss i.e. the difference between your Average Monthly Wage and the amount of money you can earn after the injury.
MY WORKERS’ COMPENSATION CLAIM WAS DENIED, WHAT DO I DO NOW?
If your claim is denied by the insurance company or Special Fund/No Insurance Section, you will have ninety (90) days from the date of the denial notice to appeal the denial by filing a “Request for Hearing” with the Industrial Commission of AZ. If the Notice of Claim Status is not protested within 90 days of issuance, it will become final and you are foreclosed from ever seeking or requesting medical or disability benefits for the injury in question.