What Is Workers’ Compensation Adjudication?

Suffering an injury on the job can be physically and emotionally traumatizing. Depending on how severe your injury is, you may need to take time off work or have surgery. You may even sustain a permanent disability. Most injured employees find it comforting that they are protected from their recovery’s financial consequences under workers’ compensation. If you are an eligible employee, you may receive benefits for medical expenses and lost wages. 

Unfortunately, getting the benefits you deserve isn’t always easy, especially if your employer or the insurance company is trying to deny your benefits. At The Law Office of William L. Phalen in Kansas and Missouri, we help injured workers receive the workers’ comp benefits they deserve. This guide to the adjudication of claims will answer your questions and help you navigate the process if your workers’ comp claim goes to adjudication.

Filing for Workers’ Compensation

Workers’ compensation is accident insurance mandated by the state and paid for by your employer. This insurance is intended to protect both you and your employer if you are injured or get sick on the job or due to working conditions. Whether you qualify for workers’ comp benefits depends on your state of residence. If you are a Missouri resident, for instance, you may be able to receive benefits if your employer has at least five employees.

If you want to file a workers’ compensation claim, collect and document the facts of your case and follow the steps below:

1. Report Your Injury or Illness Immediately 

As soon as you are injured or notice your injury, report it to your employer. Too often, workers feel minor pain, such as a strained or pulled muscle, and dismiss it. You may believe you’ll feel better the next day, and while this can be true, reporting the injury as soon as the accident occurs is crucial for a workers’ compensation claim.

In many states, a statute of limitations is imposed, meaning you have only a certain period of time to report your injury: 

• Statute of limitations in Missouri: In Missouri, you have 30 days to let your employer know about your injury. 
• Statute of limitations in Kansas: In Kansas, you have 20 days after you seek treatment for your injury to notify your employer if you work for the same employer. If you no longer work for the same employer, you have just 10 days to notify them of the accident.

2. Be Specific About the Cause

When you report your injury, be honest and as specific as possible about what caused the injury. For a workers’ comp claim to be successful, it is important that you are able to prove the injury occurred while performing a work-related task or that a job duty significantly contributed to your pain.

If you are not completely sure what caused your pain, you can still file a claim. However, be sure you err on the side of caution by reporting pain as soon as you notice it. Some injuries are repetitive stress injuries, meaning they occur from repeated use like carpal tunnel syndrome. 

3. Seek Medical Attention

As soon as possible, seek medical attention for your injury or illness. You can be examined by your primary doctor or at an urgent care clinic. Along with being essential for your recovery, receiving medical attention is a crucial step in collecting evidence that supports your claim.

A physician will ask you about what happened, and this is your opportunity to tell them about the accident that caused your injury. Be honest and provide as much detail as you remember. If your injury or illness can be linked directly to your work, your medical report may be sufficient proof to back up your claim. 

4. File Your Workers’ Compensation Claim

After you file your workers’ comp claim, your employer will receive it, fill out the required fields and sign the form. Once you and your employer have completed the claim, it should be sent to a claims administrator. This person is employed by your employer’s insurance company or is assigned to handle workers’ compensation cases on behalf of your employer. 

A copy of your claim should be given to the claims adjuster or claims administrator within a workday after you file your claim. Keep a copy of your claim. After the claims administrator receives your claim, it will either be rejected or accepted. 

5. Receive Your Claim Approval or Rejection

How long you will need to wait to hear from your claims adjuster about your claim depends on where you live. State law sets both the workers’ compensation rules and the deadlines for responding to claims. 

In most states, your employer’s insurance company will respond in a few weeks to your filed claim. In Missouri, you may start to receive wage loss benefits after you are off work for just three days. If you’re off work for 14 days, you’ll receive payment for these three days. 

In Kansas, you may be eligible for benefits if you are off work for a minimum of seven days after reporting your injury. You will need to be off work for 21 days to receive payment for these seven days.

What Does Adjudication Mean?

Adjudication refers to the process used to resolve questions. If there are questions about whether you are able to look for work, accept work or perform work or about why you left your job, your workers’ compensation claim may go to adjudication. 

During adjudication, a determination about your claim will be made based on the information available and additional information provided by you or your previous employer. In some cases, a determination may be made on your claim after a phone call with you.

Why Does a Workers’ Compensation Claim Go to Adjudication?

Workers’ compensation claims tend to go to adjudication when they raise questions about you leaving work and looking for work. For instance, if your application states that you were fired, your claim may go to adjudication so more can be learned about your circumstances before it is determined whether you qualify for benefits. Any reason besides layoffs may trigger adjudication, including:

• Quitting
• Getting fired
• Taking a leave of absence 

Additionally, if something impacts your ability to be available and able to work, this may also trigger adjudication, such as lack of transportation, being enrolled in school or a lack of child care. 

If I Have an Adjudicated Claim, Have I Been Denied Unemployment Benefits?

If your application goes to adjudication, this does not mean you have been denied unemployment benefits. Instead, the issues or questions your application raises need to be addressed before your workers’ compensation claim can be approved or denied. 

How Does Adjudication Work?

If you separate from your employer for a reason other than lack of work, your workers’ compensation claim will go to adjudication within a few days after you file your application. During adjudication, your claim is temporarily suspended until the issues can be resolved by obtaining information from your employer or from you. Additional information may be needed to clear up missing or conflicting information. 

1. Answer Questions About Your Claim

If the issue with your application is about how you separated from your employer, you may be called with questions about your claim. If the question is whether you are available and able to work, you may receive a form in the mail that you will respond to:

• If you schedule a phone call: During the phone call, you may be asked about what occurred the day you were fired and may need to verify the dates you were employed. You may be asked what work you did, your supervisor’s name and any other questions that help determine your eligibility. Ensure that you answer this scheduled call, as your benefits may be denied if you don’t participate or return the requested information, though you can appeal this decision later.
• If you receive a form in the mail: On the form, you may be asked to send in more information to explain your circumstances. If you file online, this form will be provided for you to download. Mail or fax this information in return so a determination can be made on your application.

2. Keep Your Claim Moving

Follow the tips below to keep your workers’ compensation claim moving through the adjudication process:

• Completely fill out all information requests: Ensure you return these requests promptly. The sooner you provide answers, the sooner a determination can be made.
• Check your mailbox regularly: You may be sent additional requests for information, so keep an eye on your mailbox. If you move, update your information promptly to ensure you receive any future requests for information.
• Pay attention to the confirmation page on an information request: If you file your claim online, pay attention to the confirmation page. These requests may need to be printed, filled out and returned so that a determination can be made on your claim.

3. Continue Filing Weekly Workers’ Compensation Claims

You should continue to file a weekly workers’ comp claim during your period of unemployment. If you meet all eligibility requirements and your case is approved for payment, you will receive back payments in a single lump sum for the weeks you claimed and are eligible to receive. 

4. Receive Your Letter of Determination

You will receive a letter of determination stating whether you have been approved or denied unemployment benefits. A determination typically takes a few months. If your claim is denied, this letter will include information about how you can appeal and where you can send your appeal. 

If you choose to file an appeal, you will receive a copy of the documentation used to make the application decision. During your appeal, you may continue filing weekly claims for your period of unemployment.

5. Receive Your Workers’ Compensation Benefits

After your determination is made, your workers’ compensation benefits will be released the next day. Your benefits and back payments will be paid automatically according to the option you selected, such as debit card or direct deposit, as long as there aren’t any other issues. If you choose the debit card payment option and you haven’t filed before, it may take longer to receive your payment and card.

Adjudication vs. Arbitration: What’s the Difference?

Adjudication and arbitration tend to be confused with one another. Arbitration refers to the submission of disputes to an arbitrator for a binding decision. Adjudication is the submission of disputes to an adjudicator for an interim decision that can be binding unless there is a refusal to enforce the decision or a final judgment or arbitral award substitutes the interim decision. 

The following are specific differences between adjudication and arbitration: 

• Communications: Generally, both involved parties must participate in proceedings during adjudication, and legal representation is permitted. During arbitration, communications are typically prohibited. 
• The certainty of reaching settlement: Both adjudication and arbitration will result in a decision or award. However, with adjudication, the decision is interim and may be replaced with a final judgment or arbitral award.
• Cost: The costs of adjudication are lower than arbitration, as the hearing is faster. Arbitration costs are generally higher than mediation and litigation due to the expediency and thoroughness. 
• Level of formality: Adjudication is not as formal as arbitration, and there aren’t strict rules for evidence — though procedural rules may apply as imposed by a nominating body. Arbitration is more formal than adjudication and less formal than litigation. 
• Privacy: Adjudication is private for consensual adjudication. However, compulsory adjudication may become public, since the adjudication decision must be enforced through the court. Arbitration is private, but if the court intervenes, it may become public. 
• Remedies: In adjudication, the decision on a non-monetary issue may not be binding. Arbitration, on the other hand, is more restricted and there needs to be a legal remedy. 
• Time: Arbitration can take months or years, while adjudication takes much less time. 

Both options have their pros and cons, and an experienced attorney can help you navigate the process of either adjudication or arbitration. 

Reach Out to Our Firm for More Information

We believe in justice for everyone at The Law Office of William L. Phalen. Getting justice from a giant insurance company or a massive corporation can be challenging on your own. These companies have vast resources and high-profile legal teams, and you deserve an experienced law firm on your side who can fight against the overwhelming odds. 

At Phalen Law Firm, we have a small, passionate team of attorneys who can fight for your rights if you have been injured at work. Contact us today for a free consultation or to learn more about the claims adjudication process.