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Michigan's Workers' Compensation Act provides for reimbursement to claimant's for medical bills and prescriptions paid out of pocket, and mileage to and from medical appointments. I have submitted requests for reimbursement to the claims representative and they are ignored. What do you recommend?


Answer: Michigan's Workers' Compensation Act provides for penalties:

"If medical bills or travel allowance are not paid within 30 days after the carrier has received notice of nonpayment by certified mail, in cases where there is no ongoing dispute, $50.00 or the amount of the bill due, whichever is less, shall be added and paid to he worker for each day over 30 days in which the medical bills or travel allowance are not paid. Not more than $1,500.00 in total may be added pursuant to this section."

We recommend the following procedure for requesting reimbursement or payment from a workers' compensation carrier:

In order to submit documentation to your workers' compensation carrier (w.c. carrier) for reimbursement of out-of-pocket expenses or payment of medical bills, you will need to mail the documentation to the insurance carrier by "certified mail return receipt requested" and provide the following information.

1. Cover letter: You should prepare a short written "cover letter" explaining the particular reimbursement or payment being sought, and reference the w.c. carrier's claim number, if known.

Mileage: If mileage reimbursement is being sought, include the name of the medical facility or provider, the date of the visit, and the round trip mileage. Also, some documentation should be provided showing the reason for the trip or service, such as the doctor's note relating the visit to your work related condition.

Prescriptions & Medical Bills: Receipts must be provided to the w.c. carrier when reimbursement for out-of-pocket expenses is being sought. If you are submitting medical bills for payment, you must submit the original bill from the medical provider for that date of service. The bill must include the billing "procedure" code. Do not submit billing information received from collection agencies. If you do not have the original billing information, you should contact the medical provider's billing department and request an itemized billing statement which includes "procedure" codes.

KEEP A COPY OF EVERYTHING YOU SEND FOR YOUR RECORDS.


2. Certified Mail: The above items must be mailed to the w.c. carrier by "certified mail return receipt requested." Take the cover letter, receipts or bills and addressed envelope to the post office. Obtain a certified mail package from a postal employee and purchase the necessary postage for the certified mail fees. The postal employee should provide you with a green certified mail form and "return receipt" postcard. Write the certified mail number, which is found on the certified mail form, on the cover letter. These forms must be completed. Place the cover letter, receipts and/or bills in the envelope and seal it. Place the certified mail form sticker on the top of the envelope and attach the return receipt postcard on the back of it. A postal employee can show you how the certified mail forms are completed and adhered to the envelope. You will be provided with the top portion of the certified mail form by the postal employee at the time of mailing. The green "return receipt" postcard will be mailed back to you once the workers' compensation carrier receives and signs for your envelope.

KEEP THESE FORMS WITH YOUR COPIES OF THE COVER LETTER AND ENCLOSURES.

By following this procedure, if the w.c. carrier denies receiving this particular mailing, your copy of the letter, enclosures and certified mail receipts will be evidence that those items were enclosed in the certified letter with the certified mail number on the cover letter.

3. W.C. carrier's response: If the above procedures are properly followed, requests for payment or reimbursement must be paid or "disputed" within thirty (30) days, or the w.c. carrier becomes subject to penalties. Beginning thirty (30) days from the date the w.c. carrier signs for the certified mail, if the items are not paid or "disputed," the above stated penalties apply.

4. Contact this office:
If the w.c. carrier fails to pay the requested item within thirty (30) days, or sends a "Notice of Dispute," then you should notify us so that appropriate action can be taken on your behalf.

What benefits are injured employees entitled to under the Act?

Answer: An injured employee is entitled to wage replacement, medical and rehabilitation benefits, as a result of a work-related injury or disease.
Section 315(1) provides that after 28 days from inception of medical care, teh employee may treat with a physician of his or her own choice by giving to the employer the name of the physician and his or her intention to treat with the physician. By implication, the employer has the right to choose the physician who will provide treatment during the first 28 days. If the employer objects to the workers’ selection, it may file a petition with the agency and show cause why the worker should not continue treatment with that physician. It has been held that the agency may rule only that treatment with a particular physician is not appropriate. It may not give the employer or an insurance carrier complete discretion to choose future treatment. Nor may the employer dictate a particular treatment because it believes that the treatment is the most optimal or the best of various alternatives. The commission has held that a given treatment need only be reasonable, necessary, and legal. Of course, a treatment that is far more costly than a less expensive procedure may not be deemed to be reasonable.

Weekly compensation benefits may be claimed as long as a work related disability and wage loss continues. An injured employee is entitled to reasonable medical care for work related injuries or diseases. This includes medical, surgical, nursing and hospital services and under certain conditions, dental care, crutches and such artificial appliances as limbs, eyes, teeth, eyeglasses and hearing aids. If an injured worker is able to do some work but is unable to perform work for which he or she had previous training or experience, the injured worker is entitled to vocational rehabilitation which includes counseling, guidance, specialized job placement or short-term retraining.

Do all employers carry Workers’ Compensation Insurance?

Answer: No. However, if a private employer has three or more employees at any one time, or employs one or more workers for 35 or more hours per week for 13 or more weeks, the employer is subject to the Workers’ Disability Compensation Act.

What recourse do I have if my employer requires that I perform work beyond the restrictions recommended by my doctor?

Answer: You should always follow you doctor’s recommendations, as to work restrictions. If the employer refuses to adjust your work requirements to fit within the restrictions set by your physician, contact an attorney and request that arrangements be made to request a hearing before a Magistrate, to resolve the issue.

How is my wage benefit calculated?

Answer: The injured worker’s wage replacement benefit is determined by calculations establishing 80% of the after-tax value of the gross average weekly wage, based on the highest wage average for 39 weeks in the past 52 weeks, prior to the date of injury or the last day worked, but not exceeding a fixed State Average Weekly Wage amount. The weekly wage benefit, however, is sometimes subject to coordination with other benefits that the injured worker receives, as a result of the disability or the lack of employment available.

When must I report an on-the-job injury?

Answer: Details of work-related accidents or disease should be reported as soon as possible to the employer, supervisors or other persons in charge. Failure to give notice within three months may result in loss of rights to compensation.

Is it possible to receive a lump sum advance from future compensation payments or settle my case?

Answer: Yes. In certain cases, the Magistrate may allow you to draw all or part of your compensation in one sum. The Magistrate can order that the present value of some or all of the employer’s established liability be paid to you, even though the employer may object to such payment. Alternatively, a lawyer may be able, in an appropriate case, to negotiate a settlement or redemption of the employer’s liability through the payment of a single lump sum to you. You are not required to accept such a settlement. The Magistrate must approve each settlement before they become final. The settlement becomes final fifteen days after the Magistrate’s approval.

Must I submit to medical examinations arranged by my employer?

Answer: Yes. If you are an injured worker or have claimed a work related disease and are receiving workers' disability benefits, your employer can request, from time to time, that you submit to an examination by a doctor of the employer’s choice. Unreasonable refusal to do so will most certainly result in the discontinuation of benefits.

If my employer makes a "favored" or "light duty" job available to me, within the restrictions set by my doctor, must I accept that position, even though the job pays less than my regular job?

Answer: Yes. If a valid offer of a another position is made by your employer, within the restrictions set by your doctor, you are required to accept the position, but may be entitled to continued partial compensation, where your earnings are less that that earned on the previous job.

Does Michigan have a statute of limitations for workers' compensation cases?

Answer: Michigan has a provision in its workers' compensation statute which provides for procedures and limitations on both notifying an employer of an injury or disability and the employee filing a claim for benefits as follows:

"The employee shall provide a notice of injury to the employer within 90 days after the happening of an injury, or within 90 days after the employee knew, or should have known, of the injury."

Notice may be either written or oral. It has been held to be sufficient if notice is given to a person who has authority to receive such information on behalf of the company. As not all instances of disability arise out of a single event, when disability arises, the employer should be advised of the disability and that it is related to work activity.

Michigan's statute differentiates between "notice of injury" and "filing a claim for benefits" and states:

"A claim shall not be valid or effectual for any purpose under this chapter unless made within 2 years after the later of the date of injury, the date disability manifests itself, or the last day of employment with the employer against whom the claim is being made."

A claim for benefits, medical or wage loss, may be either oral or in writing. Also, it need not be a formal claim through the Workers' Compensation Agency. However, there must be an affirmative claim for benefits.

A notice of an injury or the voluntary payment of benefits by the employer
may not satisfy the "claim" requirement. Once an affifmative claim is made for
benefits for a work related injury, that claim is good for all time with
respect to that injury. Therefore, some record or documentation of formally
making the claim should be maintained for future proof that a claim was
appropriately made.


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7264 North Sheldon Road, Canton, MI 48187
Phone: 734-455-9100, Fax: 734-455-4826, Email

 


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