Anatomy of a Workers’ Compensation Claim: Part IV

Anatomy of a Workers’ Compensation Claim: Part IV

Workers Compensation

  • Burden of proof.

The injured worker or injured employee, bears the “burden of proof”

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in establishing their claim. In a criminal case the State or the prosecutor must establish their case “beyond a reasonable doubt.” In a civil case, like a Worker’s Compensation claim or an auto collision claim, the burden is not as extreme or difficult. The burden does, however, still rest with the injured worker who is the person bringing the claim. The injured worker must establish his/her claim “by a preponderance of the evidence”. A preponderance of the evidence means more likely than not or that if you weighed the two sides of the case on a scale, the evidence in favor of your claim would tip the scale toward you even by one percent. Another way of looking at is to assume the decision maker must believe your case is stronger than the defense by at least a 51% to 49%. Remember: the burden rests with YOU. The defense or insurer need not prove anything. YOU must prove entitlement to whatever benefits you seek.

  • Standard of proof.

Standard of proof is different than burden of proof. Burden of proof relates to the strength of your case relative to the strength of the defense’s case. Standard of proof is the minimum standard you must reach in order for the Workers Compensation Court to award your benefits. In Worker’s Compensation cases, in order to be awarded any type of workers compensation benefits, you must establish your work injury “substantially contributed” to the need for medical expenses, wage loss

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or vocational rehabilitation assistance you are claiming. Substantial contribution does NOT mean it’s the only cause for a condition. For example, a person may have number of reasons that their back is injured and requires medical care. They may have hurt it years earlier or had surgery years ago. As long as the work activities or incident is substantial among the reasons for the need for care, then you can prevail in a workers compensation court.

How

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do you prove that your work activity substantially contributed to the need for your medical care? Worker’s Compensation claims must be established with a professional, or expert, opinion. Your testimony that your work activities hurt your back will not be enough to sway a judge. Your expert opinion is held to a certain standard of care.

The standard of proof for a professional medical opinion, for example, requires that the doctor issue his/her medical opinion to a “reasonable degree of medical certainty”. That means that the doctor must be willing to testify to a reasonable degree of medical certainty that he/she believes the opinion they offer is supported by evidence. For example, if you are trying to obtain payment for a medical bill, you must establish 3 basic things and your expert (usually

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your doctor) must be willing to testify that these three things are true to a “reasonable degree of professional certainty.” First, as mentioned above, that your work activities or injury substantially contributed to the need for the treatment. (You may hear lawyers/judges/specialist at Department of Labor and Industry or Office of Administrative Hearings use the words “causation”, “causal connection” or” causal nexus.” Second,

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your expert must state that the treatment is reasonable (from a cost perspective) and third, necessary (meaning the treatment is required to improve you condition) to

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cure or relieve the effects of that work injury.

Now that you know how to give notice and file a claim and what support you will need for that claim, we will focus net time on how to make sure your experts will have what they need to issue the opinions necessary for you to be successful in front a judge or specialist at the Workers compensation division. Again, some of these issues are extremely complicated and legally specific. It is often in your best interest to at least consult with a lawyer and discuss some of these issues before deciding if you feel like you can proceed and be successful on your own. Most lawyers are happy to offer a free consultation and answer questions for you.

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