Workers Compensation attorney Phillip B. Shell has been successfully representing injured workers for over 30 years. A true expert on the system and its many complexities, Phil develops creative solutions that provide injured or ill workers with needed compensation while addressing the employer's concerns when possible. Although his first approach is to seek win-win solutions, he will also pursue matters through the Utah Labor Commission and beyond. He has received accolades from Utah Business Magazine and has been a featured speaker at many legal education seminars, and is dedicated to helping sick and injured workers and their families.
Call Phil to discuss your claim. The initial consultation is free, and if you choose to retain him you'll only pay if he settles or wins your case. He represents clients throughout Utah as well as many states with Utah-related claims. He has the experience to help you. He is available for appointments during our normal business hours (Monday - Friday, 8:30 a.m. - 5:30 p.m) as well as during evenings and weekends.
Call or email today to schedule a free, no-commitment consultation with Phil
Additional Information About Workers Compensation
- Occupational Diseases
- Occupational Diseases with Multiple Employers
- Reporting an Occupational Disease Claim
- Workers Compensation Overview
The Six Basic Benefits Available for Injured Workers and Their Families through the Workers' Compensation System in Utah
1. Medical Care - there is no time limit or dollar limit for injury or illness related care.
2. Temporary Total Disability compensation - a percentage of wages paid during medical recovery.
3. Temporary Partial Disability Compensation - a percentage of lost wages if working on light duty during the period of medical recovery.
4. Permanent Partial Disability Compensation - money paid for a certain number of weeks for permanent limitations due to the injury or illness, based on wages and the impairment rating given
5. Permanent Total Disability Compensation - lifetime disability pension paid if the injured worker is unable to return to full-time gainful employment. Can be paid in addition to Social Security Disability benefits, but with certain limitations or conditions.
6. Death/Burial Benefits - weekly compensation paid to the spouse and minor children or dependents of a deceased worker, plus a one-time burial benefit.
Under Utah law, as in most states, an injured worker does not have the right to sue the employer when there is an on-the-job injury, even if it is the employer's fault. The only exceptions are when the employer did not have workers' compensation coverage at the time of the accident and when the worker was intentionally injured by the employer. If the employer did not have workers' compensation coverage and suit against the employer is not deemed to be worthwhile, a worker's compensation claim can still be made and it will be paid either by the employer directly or by the so-called Uninsured Employer's Fund.
Medical Expenses and Care
The responsibility for payment of all medical, medication, nursing, and hospital expenses incurred in connection with a compensable work injury lies with the employer and/or its insurance carrier. When the Workers' Compensation Act and Labor Commission rules are properly followed, no responsibility for payment of medical should fall upon the injured worker or his family.
A medical provider in the State of Utah may not bill the employee or the employer for the remaining balances from medical expenses not covered under the RBRVS. Utah Code section 34A-2-401 of the workers compensation act provides that the responsibility for compensation and payment of medical, nursing, and hospital services and medicines, and funeral expenses provided under this chapter shall be on the employer and the employer's insurance carrier and not on the employee.
However, workers who are treated in other states may be responsible for that portion of the bill for injury related healthcare that is not paid or covered under the RBRVS schedules. It may be in a worker's best interest financially to receive treatment in Utah following an injury even though he or she may actually reside in a neighboring state.
Coverage for payment of medical care extends to treatment rendered by all licensed medical practitioners in the state in which such person practices. Hence, it includes not just Utah practitioners, but health care providers throughout the United States.
Rule R612-2 of the Utah Administrative Code contains provisions relating to rules for health care providers in the workers' compensation system. It is required reading for all insurance adjusters and others responsible for the payment of claims. It regulates how fees and medical bills are to be paid.
Rule R612-2-8 provides that the employer has the first choice of physicians for an injured employee following an industrial accident. However, the employee may choose his or her own physician if the employer fails or refuses to provide medical attention. The injured employee may also seek emergency medical care if the physician employed in the employer's medical program is unavailable for any reason.
An injured worker may be seen by any health care provider to whom he is referred by the treating physician. There is no limit to the number of referrals which may appropriately be made for treatment or consultation. However, an injured worker has the right to only a one-time change of doctors without a referral and without the need for permission from the insurance carrier, as long as the carrier is promptly notified of the change. Changes from emergency room facilities for the initial visit, following a work injury, to a private physician are not considered part of the one-time right to change.
Injured workers who do not follow the rules with respect to changes in medical care providers may be faced with having to pay for such medical care themselves.
Once a worker is receiving medical care, if surgery is required, and it is not a life or limb threatening hospital admission, then pre-authorization of the procedure is required from the employer or insurance carrier. The carrier must provide an answer to the physician and the injured worker within 2 working days of a telephone request concerning approval or denial of the requested procedure. Four days are allowed for an answer if the request was made in writing.
A third option beyond approval or denial is the possibility of a medical examination of the injured worker in an IME, to be scheduled by the carrier. If this is to occur, it must be conducted within 30 days in most circumstances. While the insurance industry calls these Independent Medical Examinations, they might better be called Insurance Medical Examinations. Not all examiners are fair and unbiased in their exams. However, it the insurance carrier requests that you need to go to an IME, you should go, or you will be deemed to be non-cooperative.
If the injured worker proceeds for medical care without pre-authorization, the responsibility for the medical costs, as well as the weekly disability compensation that would otherwise be paid during recovery, may lie with the injured worker unless a determination is subsequently made in his or her favor. This could be either a favorable review resulting from the IME, or a favorable order by an Administrative Law Judge at the Labor Commission following a hearing and possible medical panel review.
It is not uncommon during the rendering of medical care that an employer or insurance carrier request that a nurse case manager, or other representative of the employer/carrier, appear with the injured worker at his or her medical exam with the treating physician. However, Rule R612-2-25 provides that whether or not the nurse case manager can actually be present during the examination time itself is wholly at the option of the injured worker. However, if the worker asserts the right to privacy during the exam, then the doctor AND the injured worker shall meet with the agent at the conclusion of the visit to allow for communication about medical care and return to work issues.
There is no limit on the amount of or when medical bills can be incurred for a work injury or illness. However bill for medical services must be submitted to the workers' compensation insurance carrier for payment within one year of treatment date or it will not be payable.
An injured worker's right to the amount of payment of disability compensation is based on a formula set forth by statute. In most cases it is fairly easy to calculate the weekly disability rate.
For the weekly indemnity payments an injured worker may receive while recovering from an injury, the Utah statute provides that an injured worker is entitled to 2/3 of his average weekly wages at the time of the injury, plus $5.00 per dependent (up to a maximum of 5), or the State Average Weekly Wage, whichever is less. How much your weekly maximum is will be based on the year in which you were injured. Weekly benefits are known as Temporary Total Disability Compensation.
For the purpose of calculating the Permanent Partial Disability rate, the formula is the lesser of 2/3 of the employee's wages at the time of the accident, plus the dependency add-on, or 2/3 of the State Average Weekly Wage for the year in which the person was injured. Hence, the maximum rate is 66.66% of the temporary total disability rate.
For Permanent Total Disability Compensation and death benefits, the rate is either 2/3 of the employee's wages at the time of injury, plus the dependency add-on, or 85% of the State Average Weekly Wage, whichever is less.
The presumption of dependency extends to the spouse of the injured worker and minor children of the injured worker for whom he or she has an obligation for support. Dependency is usually determined at the time of the industrial accident or occupational disease. However, under certain circumstances, dependency may extend beyond the time a child reaches age eighteen. Such extensions depend heavily on the facts and circumstances of each case. Hence, stepchildren, disabled adult children and others may be considered dependents.
When the injured worker does not have regular hourly wages, the computation of the average weekly wage is determined pursuant to Section 34A-2-409, U.C.A.
When wages are fixed by the year, the average weekly wage is determined by dividing the yearly wage by 52.
When wages are fixed by the month, the average weekly wage is the monthly wage divided by 4.33.
When wages are fixed by the day, the average weekly wage is determined by multiplying the daily wage by the greater of the number of days and/or parts of days in the week during which the employee was working at the time of the accident or would have worked if she had not been hurt OR three days.
When wages are fixed by the hour, the average weekly wage is determined by multiplying the hourly rate by the greater of the number of hours that the employee would have worked during the week had the accident not occurred OR 20 hours.
When wages are based upon output or piece rate, you look at the 52 week period preceding the accident and you choose the best quarter of the four quarters (a 13 week period) during that year, take the sum of all regular wages paid (not including overtime) during that quarter and divide by 13. However, if the employee has worked for less than 13 weeks before the injury, wages are to be paid on what the employee would have earned during the 13 week period before the injury in light of work available to other employees in a similar occupation during that period.