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Five things to know


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Five things to know

  1. 1. Hearing Preparation:Where “Know” Is Not A Negative Word
  2. 2. Know The Issue
  3. 3. 1. KNOW THE ISSUE A. Claim/Condition Allowance (1) Initial Claim Allowance can mean ER does not think acc happened or if accident happened it did not cause any injury or accident did not cause the specific injuries being requested (2) Additional Allowance Almost always involves medical causation and requires medical support
  4. 4. 1. KNOW THE ISSUE B. Payment of Benefits primarily involves whether claimant is eligible for payment or correct calculation of payment, FWW and/or AWW C Authorization for Medical Treatment Starts with a C-9 authorization for treatment (there can be multiple C-9s in various stages of authorization/denial, so make sure you have the correct one) State fund v. Self Insured and how to get the treatment to hearing including appeals Always requires greater support from treatment requesting doctor
  5. 5. 1. KNOW THE ISSUE D. Any combination of A, B, and/or C Initial allowance—payment of benefits may be included if supported Additional allowance—B and C may be involved if both C84 and C9 are part of motion. E. Procedural Issues see “Know The Procedure”So when you are preparing for an upcoming hearing—start with whatis the exact issue involved. Tip: Check the hearing notice since itshould give you notice of the issue.
  6. 6. Know The Evidence
  7. 7. 2. KNOW THE EVIDENCE A. Now that I know the issue, what do I need to prove?
  8. 8. 2. KNOW THE EVIDENCE B. Allowance of claim (1) Accident accident report—very important have to be able to explain delay statements from witnesses not just those that actually saw what happened “He told me he had just hurt his back” on DOA review 1st history given to health care provider (2) Repetitive trauma careful review of mechanism of injury Take a moment to talk about it Need to be able to answer the question: Why now?
  9. 9. 2. KNOW THE EVIDENCE B. Allowance of claim (3) Occupational disease review what the requirements are: basically that the work creates a unique hazard claimant has a greater risk of exposure develop your facts around these requirements (4) Keep in mind that you still need medical causation what doctor says that the injuries were caused by the accident
  10. 10. 1. KNOW THE EVIDENCE C. Additional allowance (1) Who is supporting the additional condition, i.e. which health care provider says that the additional condition was caused by acc. (2) Where does the evidence come from? On a C-9 Separate causation statement from doctor C30 form carefully tailored to the issue
  11. 11. 1. KNOW THE EVIDENCE D. Payment of benefits (1) Temporary Total (a) Correct C-84 filled out by treating doctor with correct allowed conditions and current up to time of hearing (b) Medical evidence that claimant was being actively treated during disability period of waiting for surgery to be approved (2) Wage Loss (a) too many requirements to cover here (b) one tip that you should know—under the OAC, an employee does not have to apply to Ohio Job and Family Services if he returns to same employer at a job paying less money and seeks a wage loss.
  12. 12. 1. KNOW THE EVIDENCE D. Payment of benefits (3) Permanent Partial (a) If you are going to hearing on this, you must have medical evidence to support the appeal (b) Make sure all helpful records are imaged before filing C92 and are provided to claimant’s examining doctor (c) Place the impairment reports side by side and see if you can see the differences between the two— usually it’s a matter of degree of severity found and/or quality and thoroughness of examination
  13. 13. 1. KNOW THE EVIDENCE E. Authorization for Treatment (1) If State Fund—review the ADR packet paying particular attention to the physician’s review of the treatment. (2) If there is time, obtain response from treatment seeking doctor to physician’s review (3) If the treatment has provided relief to the claimant before and more treatment is being requested, have claimant testify about the positive results of the treatment.
  14. 14. Know The Procedure
  15. 15. 1. KNOW THE PROCEDURE A. File your R2 as soon as possible B. State fund or Self Insured C Avoid being ambushed D. Avoid ambushing the other side E. Understand time limits and keep track of due dates
  16. 16. Know What The Employer Is Going to Argue
  17. 17. 4. KNOW WHAT THE EMPLOYER IS GOING TO ARGUE A. Once you know the issue and the evidence you need, consider the employer’s position. B. Construct the employer’s argument in your mind and review the claim file for evidence that will support that argument C. To the extent that a medical issue is involved, review the employer’s IME carefully to understand how the employer is going to argue D. Once you have identified the employer’s arguments as bestyou can, comb through the evidence that will refute or dilute each argument and be prepared to point out that evidence to the IC hearing officer Tip: Look up the employer’s doctor online at the Ohio State MedicalAssociation web site and determine if the doctor actually has expertise forthe injury that you are in hearing about.
  18. 18. Know What To Do Next
  19. 19. 5. KNOW WHAT TO DO NEXT A. If you win— (1) Understand appeals (2) Additional Allowance/Medical treatment (3) Payment of benefits B. If you lose— (1) Understand appeal time (2) Review order for reasoning and, where possible, obtain evidence that will refute reasoning at next hearing (3) When in doubt, appeal (4) Appeal up through appeal to IC commission every time
  20. 20. 5. KNOW WHAT TO DO NEXT C. When to refer (1) On every allowance issue that is lost (2) If you do not understand reasoning of IC order (3) If order seems based on legal case or cases (4) If you can’t think of a way to refute IC reasoning (5) If you are not sure what to do next
  21. 21. So What Do We Need To Know To Prepare For A Hearing?• 1. Know The Issue• 2. Know The Evidence• 3. Know The Procedure• 4. Know What The Employer Will Argue• 5. Know What To Do Next