INFORMATION FOR THE INJURED WORKER

Introduction

If the injury or illness is job related, the injured worker receives medical benefits and, if eligible, temporary compensation. In some cases, the injured worker may also receive permanent compensation and "job retraining."

The Industrial Commission of Arizona and the insurance carrier are not identical. The Industrial Commission is a state agency that is responsible for deciding disputes and monitoring the activities of the State Compensation Fund, private carriers and self-insured employers, referred to in this pamphlet, as insurance companies.

One final item - as you read this pamphlet, please pay special attention to your rights and responsibilities. Failure to meet these responsibilities can mean the loss of your rights and benefits under Arizona's Workers' Compensation Law.

The hospital or doctor sends the original of the form to the Industrial Commission (ICA), a copy to your employer and a copy to the insurance company that wrote the policy for your employer. If you did not complete this pink for at the doctor's office or at the hospital, another form, entitled "Worker's Report of Injury," can be completed and filed with the Industrial Commission. This form will be sent to you by the ICA upon request.

Your claim is officially filed when one of these forms is received by the Industrial Commission. Without a claim signed by you or your legally authorized representative and received by the Industrial Commission, the insurance carrier is not legally required to take any action on your injury or to make any payments. You will know that the claim form has been received because the Industrial Commission will notify you by letter. If you are not notified of the receipt of your claim within a reasonable period of time, (two weeks), please contact the Industrial Commission and claim form will be sent to you to complete and return.

Remember, that your claim must be filed within one year of the date of injury and that you are responsible for making sure that the claim is filed.

When your claim is received by the Industrial Commission, the insurance company is officially notified by the ICA that you have filed a claim. The insurance company must then either accept or deny your claim within 21 days from the date of the notification. If your claim is denied, you will receive a "Notice of Claim Status" from the insurance company. If you disagree with the insurance company's denial, this notice will have a 90 day protest period within which you must file your request for hearing with the Industrial Commission by means of letter or on a form available from the ICA upon request. This request for a hearing must be signed by you and your legal representative.

If you file a request for hearing, you will receive a Notice from the Industrial Commission which will tell you when a hearing before an Administrative Law Judge will be set. If you do not file a request for hearing during the 90 day protest period, the decision of the insurance company becomes final.

Remember, it is your responsibility to understand all notices and documents which allow for hearing requests in the event of disagreements, and it is also your responsibility to make your current address known to the Industrial Commission and the insurance company.

On medical only claims, the insurance company does not have to let you know that they are accepting the claim and can assume all medical bills will be paid. Even though you do not lose time from work, you will continue to have your medical bills paid until the doctor states you have recovered and do not need further treatment. If you stop treatment because you believe you have recovered, the carrier may close your claim without the doctor's discharge.

Once the claim is accepted, you are not responsible for the payment of any medical expenses for treatment related to your injury. If you receive a bill and are being asked to pay it, call your insurance company to find out why they have not paid it.

While you are under active medical care, it is important for you to remember that the insurance company has the right to have you periodically examined, at a reasonably convenient time and place, by a doctor of its choosing. Failure to attend the examination could result in suspension of your benefits, and you could be required to pay for the cost of the missed examination. The insurance company may accept the opinion of its consulting doctor and base a change in you claim status, or the closure of your claim, on that doctor's opinion.

The first 7 days off are not paid for lost wages unless your disability extends to 14 days. For example: If you are off 10 days, you will get paid for days 8, 9, and 10 only. If you are off 14 full days, compensation is retroactive (goes back to the date of injury and you are paid for 14 days. Compensation is not generally paid for the date of injury because you were working that day.

Compensation is paid at 66-2/3% of your average monthly wage. The average monthly wage is usually calculated on your earnings during 30 days before your injury, although there are other methods for calculating the average monthly wage. The law establishes a maximum figure which can be used to calculate the average monthly wage. As of July 1, 1991, the maximum monthly wage is $2,300.00. Even though you earned more than $2,300.00 per month, the most a person can receive is 66-2/3% of $2,300.00. The wage is set as of the date of injury. The law does not allow for cost of living increases.

If you are losing time from work, the law requires that the insurance company inform you that your claim is being accepted by sending you a Notice of Claim Status form with your first temporary compensation check. The Notice will tell you the wage as calculated by the insurance company. A second form, Wage Calculation Sheet, should be attached to the Notice. This form will explain how the insurance company arrived at the figures. The same information is also sent to the Industrial Commission for review.

The ICA reviews the insurance company's calculations and issues and the Notice of Average Monthly Wage which sets the wage. If the wage is not calculated correctly, the ICA can disapprove the wage and establish the correct wage. Because the ICA's review covers only the reasonableness of the data and the accuracy of the calculations, it will send you, the injured worker, a letter seeking your assistance in verifying the accuracy of the figures used in the calculation. If there is a question regarding the accuracy of the data used in calculating the average monthly wage, you are asked to contact the Wage Section of the Industrial Commission's Claims Division.

Remember, you only have 90 days from the issuance of this Notice to protest the accuracy of the average Monthly Wage. After that period, the Notice becomes final and can only be appealed under very restricted circumstances. Again, to avoid any delay or loss of benefits, make sure the insurance company and the Industrial Commission have your current address.

While under active medical care, a doctor may release you to return to work, light duty or your regular job. If that happens, that status of your claim changes. Your insurance company will officially tell you of the change in your work status by insuring another Notice of Claim Status form informing you of the date you are released to return to work. You must report those efforts to the insurance company on a form provided by it. Once released to work, continuance of temporary compensation benefits is not automatic or guaranteed.

The insurance company will review each case to determine if temporary benefits will continue. If it is determined that you have a loss of wages because of your injury, the insurance company will pay 66-2/3% of the difference between the wages you are now able to earn and the average monthly wage. This compensation is paid once a month instead of every two weeks.

While you are under active medical care, it is important for you to remember that the insurance company has the right to have you periodically examined, at a reasonably convenient time and place, by a doctor of its choosing. Failure to attend the examination could result in suspension of your benefits, and you could be required to pay for the cost of the missed examination. The insurance company may accept the opinion of its consulting doctor and base a change in your claim status , or the closure of your claim, on that doctor's opinion.

Again, if there is a change in the status of your claim, you will receive a "Notice of Claim Status" from the insurance company identifying the change.

When you have recovered from your injury, the doctor will report this to the insurance company, and your claim will be closed to temporary compensation benefits as of the date your doctor discharges you from treatment. The insurance company will issue a new Notice of Claim Status telling you your claim is closed and the date of closure.

Remember, it is your responsibility to understand all notices. If you disagree, you must file your request for hearing with the ICA within 90 days from the date of the "Notice of claim Status" or the Notice becomes final.

The percentage of impairment is usually rated by the doctor in accordance with standards as published by the American Medical Association in Guided to the Evaluation of Permanent Impairment. Compensation for permanent injuries is generally paid once per month.

Compensation is calculated in three different ways for scheduled injuries: For partial loss, you will receive 50% of the average monthly wage; for a loss that is the result of an amputation, you will receive 55% of the average monthly wage; and the permanent injury prevents you from returning to your regular work, you will receive 75% of the average monthly wage.

The Industrial Commission will calculate your unscheduled permanent partial compensation at 55% of the difference between your average monthly wage and the amount they estimate you will be able to earn (reduced earning capacity) given your injury. The Claims Division if the Industrial Commission will send you a form entitled "Findings and Award for Unscheduled Permanent Partial Disability," explaining the amount of money you will be receiving each month. The money is paid by the insurance company and is retroactive (goes back) to the date of discharge by the doctor(s).

If you, the employer, or the insurance company disagrees with this award, a request for hearing must be filed within 90 days form the issuance of this award. 

Keep in mind that from the time you are discharged form treatment to the time the Industrial Commission issues its "Findings and Award for Unscheduled Permanent Partial Disability," the insurance company is not required to continue compensation. They may voluntarily continue to pay. If the amount, however, is larger than what is found in the award issued by the ICA, it will take a credit against future payments. Once the award is issued by the ICA, the insurance company is required to pay the amount on the award, even if it disagrees, until the amount of permanent compensation is finalized through the hearing process. Once the amount of permanent compensation has been finalized, that amount will be paid monthly by the insurance company.

Each year, on the anniversary date of the award, the insurance company will send you are form entitled "Annual Report of Income." You must report on that form how much you earned as wages during the past 12 months. The form must be sent to the insurance company, not the Industrial Commission. If you fail to return to form, your permanent compensation payments may be suspended until you file the form. Remember, your permanent compensation benefits can only be stopped by:
(1) Your death
(2) Failure to file an "Annual Report of Income"
(3) Rearrangement of your benefits by the ICA following a petition by the employer of the insurance company, of which you will be notified.

There are approximately 90 employers in the state who have been given this authority.