EP 34: Workers Compensation Claims Process for Catastrophic Injuries (Part 1)

Welcome to the catastrophic comeback podcast with American Injury Lawyer Clark speaks, helping you find hope, purpose and joy after a catastrophic injury.

Hi, welcome to catastrophic comeback. I'm excited today to have my guest, Chris Miranda, Chris Miranda is a senior worker's compensation paralegal at speaks law firm. Welcome, Chris. Thank you for being here.

Thanks for having me.

Chris. First, tell me a little bit about your background. And you know, how you became involved in working at the worker's compensation field and how long you've been doing it, that sort of thing.

I've been involved in the industry in a couple of different ways for little over 30 years now. When I moved to Wilmington, from New York, I bounced around job to job for a little while. And about 20 years ago, I landed at a nother law firm here in town. And the only thing that was available was workers comp. So I just tackled it. And I've been doing it ever since that. Well. So

let me ask you this. When you you moved here from you moved to North Carolina from New York? Yes. And what kinds of work did you do in New York,

I worked for the I work for liberty mutual insurance company, the last thing I did for them there was as a team manager, so I had four or five people reporting to me probably 1500 cases that we were responsible for

big cases, small cases, high value cases, medium value, low value

is kind of a combination of all that, you know, we had car wrecks, and we had slip and falls and premises liability cases. But we handled a variety of different cases, the way they're set up was back then was that if it was a catastrophic loss, it just straight it went straight to our home office, which is Boston and New Hampshire.

So you've been in the injury space for more than 30 years?

Yeah, when I first started, I worked in the construction unit for Liberty Mutual, and we covered all five boroughs in New York City. And you learn a lot really quick, because it's not people who are just spraying in their backs or spraying in their ankles, it's guys who are falling off buildings and shattering both their ankles or breaking their backs and things like that. So it was a good baptism into the medical part of things. So I really credit that with my, what I know about the medical field, and what I've how I've used it in this career.

Well, I think that's something I wanted to talk to you about, because the focus of this podcast is catastrophic injuries and, and how they affect people and how we can help those kinds of people or how some someone can help those kinds, those people that are in that involved in that process. So you talked about your background, and you're in New York and dealing with these kinds of cases. And, and is there a difference in your, in your observation with dealing with cases where people are less seriously hurt versus dealing with these catastrophic cases?

You know, you'd like to say that every case is the same. But there's just more. You've got to act quicker, I guess, in a catastrophic case. And, obviously, he's going to take up a lot more of your time. But yeah, it is different, you know, your basic run of the mill case, if there really is one, you know, you can kind of do the same things over and over again, but a catastrophic case, you're gonna get thrown curveballs all the time, and things that you don't expect. So you've kind of got to be more on your toes for those types of cases.

So we'll come back to that in just a minute. Listen, you mentioned sort of the more run of the mill garden variety case, we understand I understand, I think everybody understands that all cases are different. And they require, you know, specialized focus. And, and, and we want to, you know, treat everybody as an individual not as a number for sure that I think that goes hopefully that goes without saying. But with respect to it is true that most a lot lots of B, C, C, C, on a day to day basis, we might see a lot of shoulder injuries might lead to knee injuries, a lot of ordinary back injuries, a lot of ankle injuries, those kinds of things, and somebody might be out of work for six months, yep. They'll have a prescribed course of treatment at the end of that they might have some work restrictions and those kinds of things. So let me so let me ask you, can you walk me through that process of of a more or have a have a worker's comp case case that is serious enough to affect someone's ability to work and require medical attention and require a workers compensation claim to be opened and pursued, but not so serious as to where we would consider it catastrophic. Just procedurally what are the elements? What goes on in a case like that?

Well, you know, we've first you've got to make sure that there's insurance coverage for this person, right. So in North Carolina, if you employ three or more people, you're supposed to have insurance coverage. And just because that's the law doesn't mean that there are aren't companies out there who aren't getting the coverage that they need. So that's the first thing is, because if there's no insurance coverage, there's really not much that we can do. Because if you go after the person individually, even if you win, you just may not recover anything for your injured person. And that's really not fair to them, to put them through the process. But so if we can confirm that there's coverage, and there's different ways of doing it, you know, then we would file the necessary paperwork with the Industrial Commission, filed letters of rec with the insurance companies, and try to establish a relationship with the insurance adjuster to make sure that our client is going to get the things that they're supposed to have. So stage

one is open a claim, is that fair? Right? Yes. Okay, what's the next stage?

Well, we then we've got to start collecting information, right. So the insurance company, if it's an accepted case, they shouldn't be sending us all the medical records, they should be sending our client for treatment, they should be paying them a portion of their wages while they're out. And we need to just make sure that that process gets started. Okay, so

So the way I understand your explanation is stage two is collect documentation set up treatment and pay benefits. And if they don't do If, at any point, during this process, the insurance company who's on the other side of this claim, doesn't do that, then there are, I guess, remedies that we could avail ourselves of and try to in hearings, we could request and there's

depending on the situation, that's going to determine what our next step is going to be if something goes wrong. And, and, as cliche as it may sound, something is gonna go wrong in every case, and it may be a small something, or it may be a big something, but there's always something, you know, maybe wage benefits get cut off by mistake. And that does happen, they get the somebody doesn't hit the button, and the check doesn't go out, or they go wrong address goes to the wrong address, or somebody sets up a certain amount of payments, and then that when that time period expires, they forget to renew it, we just had a situation like that. So there's and there's different ways to combat all those things. Most of the smallest situations you can resolve with an email or maybe a telephone call or, or something like that. But you know, if there's medical treatment that's been denied, or if the case itself has just been denied, then there's methods to go to the Industrial Commission to try to push things along and come to some resolution for our client.

So stage three to me is something goes wrong. But stage three could take place at any point in this whole process. It might take place more than one, right?

And it may be right at the very beginning. Or maybe right at the end, or it could be any place on the line. Okay, stage four, what

are we looking at here? Well,

it's once the clients done with all their medical treatment, then we're going to work to try to get their case settled for them in the best in the way that's best for them. Because the way you settle for one person isn't nurse necessarily the way you want to settle it for somebody else. And

we'll talk more about what that means as process, especially when we get to when we start looking at this from a catastrophic perspective. But I see what you're saying. So then the stage four is going to be you know, where we look to mediate, settle, clench. So fair, say click clinch. What does that mean?

In North Carolina, the settlement paperwork for an all inclusive settlement. For some reason, it's called the clincher. Nobody's ever really explained to me why they call it that. It's really a settlement agreement is what it is, but that's the nickname for it. It's a really long document drawn up by the defense attorneys, just summarizing medical treatment summarizing whether they agree with something or whether they disagree with something. And it also points out, it specifies what the settlement amount is,

and what it's for so that we can because there's some of that has tax consequences, that from our perspective, representing the plaintiffs, we Got to be very careful to include certain language and write and exclude other language. Okay, so those are the those are the stages of this process. And at any point a dispute can arise and often does between us and the other. And then what's the process if and when a dispute arises?

Well, there's, again, it depends on what the dispute is. There are motions, which is that can be filed with the Industrial Commission to get them to have an informal telephonic hearing where somebody from the industry commission, usually special deputy commissioner will hear both sides and make a ruling. Or you can file for a hearing with the Industrial Commission, which is a more formal process, the ultimate end result in that is that you'll go to a hearing before a deputy commissioner who will hear testimony from the injured party, that there may be testimony from the employer. But the big part of that is going to be testimony from the doctors and any other experts that we might have. And that's a really long process. So before you ever get to that part, that part of it. The industry commission mandates that you have a mediation, which is just really talking about numbers most of the time,

where does mediation generally fall in a worker's comp context?

Well, in a perfect situation, it would be towards the end of the case. So that we have all the information that we need to make the right decisions and the right recommend recommendations to our client. But sometimes, especially like in a denied case, it's going to come up a lot sooner than we want it to. And then we have to project things and work with what we have, because our client might not have gotten all the treatment that they really needed. On

average, how long might this process take from beginning to end?

Um, you know, a normal case, for lack of a better, better term. I always tell folks that they should expect it, it's going to take six months to a year. Really, do I see where they've got to be less than six months, but I think that's a good estimate of how long it's going to take. If somebody's a little bit more seriously injured, and they have multiple surgeries, or really long recovery times, then obviously, it's going to last longer than that. But on average, hopefully within a year 18 months, something like that will go from start to finish. Thank

you for joining us, and we'll see you next time.

Welcome to the catastrophic comeback podcast with American Injury Lawyer Clark speaks, helping you find hope, purpose and joy after a catastrophic injury.

Hi, welcome to catastrophic comeback. I'm excited today to have my guest, Chris Miranda, Chris Miranda is a senior worker's compensation paralegal at speaks law firm. Welcome, Chris. Thank you for being here.

Thanks for having me.

Chris. First, tell me a little bit about your background. And you know, how you became involved in working at the worker's compensation field and how long you've been doing it, that sort of thing.

I've been involved in the industry in a couple of different ways for little over 30 years now. When I moved to Wilmington, from New York, I bounced around job to job for a little while. And about 20 years ago, I landed at a nother law firm here in town. And the only thing that was available was workers comp. So I just tackled it. And I've been doing it ever since that. Well. So

let me ask you this. When you you moved here from you moved to North Carolina from New York? Yes. And what kinds of work did you do in New York,

I worked for the I work for liberty mutual insurance company, the last thing I did for them there was as a team manager, so I had four or five people reporting to me probably 1500 cases that we were responsible for

big cases, small cases, high value cases, medium value, low value

is kind of a combination of all that, you know, we had car wrecks, and we had slip and falls and premises liability cases. But we handled a variety of different cases, the way they're set up was back then was that if it was a catastrophic loss, it just straight it went straight to our home office, which is Boston and New Hampshire.

So you've been in the injury space for more than 30 years?

Yeah, when I first started, I worked in the construction unit for Liberty Mutual, and we covered all five boroughs in New York City. And you learn a lot really quick, because it's not people who are just spraying in their backs or spraying in their ankles, it's guys who are falling off buildings and shattering both their ankles or breaking their backs and things like that. So it was a good baptism into the medical part of things. So I really credit that with my, what I know about the medical field, and what I've how I've used it in this career.

Well, I think that's something I wanted to talk to you about, because the focus of this podcast is catastrophic injuries and, and how they affect people and how we can help those kinds of people or how some someone can help those kinds, those people that are in that involved in that process. So you talked about your background, and you're in New York and dealing with these kinds of cases. And, and is there a difference in your, in your observation with dealing with cases where people are less seriously hurt versus dealing with these catastrophic cases?

You know, you'd like to say that every case is the same. But there's just more. You've got to act quicker, I guess, in a catastrophic case. And, obviously, he's going to take up a lot more of your time. But yeah, it is different, you know, your basic run of the mill case, if there really is one, you know, you can kind of do the same things over and over again, but a catastrophic case, you're gonna get thrown curveballs all the time, and things that you don't expect. So you've kind of got to be more on your toes for those types of cases.

So we'll come back to that in just a minute. Listen, you mentioned sort of the more run of the mill garden variety case, we understand I understand, I think everybody understands that all cases are different. And they require, you know, specialized focus. And, and, and we want to, you know, treat everybody as an individual not as a number for sure that I think that goes hopefully that goes without saying. But with respect to it is true that most a lot lots of B, C, C, C, on a day to day basis, we might see a lot of shoulder injuries might lead to knee injuries, a lot of ordinary back injuries, a lot of ankle injuries, those kinds of things, and somebody might be out of work for six months, yep. They'll have a prescribed course of treatment at the end of that they might have some work restrictions and those kinds of things. So let me so let me ask you, can you walk me through that process of of a more or have a have a worker's comp case case that is serious enough to affect someone's ability to work and require medical attention and require a workers compensation claim to be opened and pursued, but not so serious as to where we would consider it catastrophic. Just procedurally what are the elements? What goes on in a case like that?

Well, you know, we've first you've got to make sure that there's insurance coverage for this person, right. So in North Carolina, if you employ three or more people, you're supposed to have insurance coverage. And just because that's the law doesn't mean that there are aren't companies out there who aren't getting the coverage that they need. So that's the first thing is, because if there's no insurance coverage, there's really not much that we can do. Because if you go after the person individually, even if you win, you just may not recover anything for your injured person. And that's really not fair to them, to put them through the process. But so if we can confirm that there's coverage, and there's different ways of doing it, you know, then we would file the necessary paperwork with the Industrial Commission, filed letters of rec with the insurance companies, and try to establish a relationship with the insurance adjuster to make sure that our client is going to get the things that they're supposed to have. So stage

one is open a claim, is that fair? Right? Yes. Okay, what's the next stage?

Well, we then we've got to start collecting information, right. So the insurance company, if it's an accepted case, they shouldn't be sending us all the medical records, they should be sending our client for treatment, they should be paying them a portion of their wages while they're out. And we need to just make sure that that process gets started. Okay, so

So the way I understand your explanation is stage two is collect documentation set up treatment and pay benefits. And if they don't do If, at any point, during this process, the insurance company who's on the other side of this claim, doesn't do that, then there are, I guess, remedies that we could avail ourselves of and try to in hearings, we could request and there's

depending on the situation, that's going to determine what our next step is going to be if something goes wrong. And, and, as cliche as it may sound, something is gonna go wrong in every case, and it may be a small something, or it may be a big something, but there's always something, you know, maybe wage benefits get cut off by mistake. And that does happen, they get the somebody doesn't hit the button, and the check doesn't go out, or they go wrong address goes to the wrong address, or somebody sets up a certain amount of payments, and then that when that time period expires, they forget to renew it, we just had a situation like that. So there's and there's different ways to combat all those things. Most of the smallest situations you can resolve with an email or maybe a telephone call or, or something like that. But you know, if there's medical treatment that's been denied, or if the case itself has just been denied, then there's methods to go to the Industrial Commission to try to push things along and come to some resolution for our client.

So stage three to me is something goes wrong. But stage three could take place at any point in this whole process. It might take place more than one, right?

And it may be right at the very beginning. Or maybe right at the end, or it could be any place on the line. Okay, stage four, what

are we looking at here? Well,

it's once the clients done with all their medical treatment, then we're going to work to try to get their case settled for them in the best in the way that's best for them. Because the way you settle for one person isn't nurse necessarily the way you want to settle it for somebody else. And

we'll talk more about what that means as process, especially when we get to when we start looking at this from a catastrophic perspective. But I see what you're saying. So then the stage four is going to be you know, where we look to mediate, settle, clench. So fair, say click clinch. What does that mean?

In North Carolina, the settlement paperwork for an all inclusive settlement. For some reason, it's called the clincher. Nobody's ever really explained to me why they call it that. It's really a settlement agreement is what it is, but that's the nickname for it. It's a really long document drawn up by the defense attorneys, just summarizing medical treatment summarizing whether they agree with something or whether they disagree with something. And it also points out, it specifies what the settlement amount is,

and what it's for so that we can because there's some of that has tax consequences, that from our perspective, representing the plaintiffs, we Got to be very careful to include certain language and write and exclude other language. Okay, so those are the those are the stages of this process. And at any point a dispute can arise and often does between us and the other. And then what's the process if and when a dispute arises?

Well, there's, again, it depends on what the dispute is. There are motions, which is that can be filed with the Industrial Commission to get them to have an informal telephonic hearing where somebody from the industry commission, usually special deputy commissioner will hear both sides and make a ruling. Or you can file for a hearing with the Industrial Commission, which is a more formal process, the ultimate end result in that is that you'll go to a hearing before a deputy commissioner who will hear testimony from the injured party, that there may be testimony from the employer. But the big part of that is going to be testimony from the doctors and any other experts that we might have. And that's a really long process. So before you ever get to that part, that part of it. The industry commission mandates that you have a mediation, which is just really talking about numbers most of the time,

where does mediation generally fall in a worker's comp context?

Well, in a perfect situation, it would be towards the end of the case. So that we have all the information that we need to make the right decisions and the right recommend recommendations to our client. But sometimes, especially like in a denied case, it's going to come up a lot sooner than we want it to. And then we have to project things and work with what we have, because our client might not have gotten all the treatment that they really needed. On

average, how long might this process take from beginning to end?

Um, you know, a normal case, for lack of a better, better term. I always tell folks that they should expect it, it's going to take six months to a year. Really, do I see where they've got to be less than six months, but I think that's a good estimate of how long it's going to take. If somebody's a little bit more seriously injured, and they have multiple surgeries, or really long recovery times, then obviously, it's going to last longer than that. But on average, hopefully within a year 18 months, something like that will go from start to finish. Thank

you for joining us, and we'll see you next time.