An Admission of Liability is a statement by an insurance company acknowledging responsibility for payment of benefits outlined in the admission. Once an admission of liability is issued, an insurance company is bound to pay the benefits set forth in the admission until it can terminate benefits under the law. If you believe your benefits have been calculated incorrectly or terminated improperly, review the following information: How to...calculate your average weekly wage and what to do if you believe your wages have been reported incorrectly and What is...the criteria for terminating benefits? If, after reviewing this information, you believe there is an error, contact the Division of Workers' Compensation and ask to speak with a Claims Manager.
A Notice of Contest is a statement by an insurance company denying responsibility for payment of benefits. The basis for the denial is outlined in the notice of contest. If the reason for the denial is further investigation, you may want to contact the insurance adjuster handling your claim to determine what information is lacking and how you may assist in obtaining the necessary information to expedite review. The name and phone number of the adjuster should appear on the Notice of Contest form.
If your claim has been denied, you may be responsible for all the medical bills associated with the illness or injury. (You may then be eligible for coverage through your private health care insurance policy.) If you believe your claim has been incorrectly denied, there are several options available to you. See What is...a Prehearing Conference? and What is...an Administrative Hearing? below. If your claim is denied and you want to request an expedited hearing, you must file an Application for Hearing form within 45 days of the date of mailing of the Notice of Contest form.
Whatever the basis for the denial, the fact remains that the claim has been denied. If you wish to pursue a claim for workers' compensation benefits, it will be necessary for you to actively prosecute the claim and exercise the options that are afforded you under the law.
Prosecuting a claim means to follow through with actions to obtain benefits until a final determination is made. Prosecution of a claim may include requesting a hearing, participating in a prehearing conference for the purpose of resolving issues, engaging in good faith settlement negotiations, obtaining medical evaluations and reports necessary to prove the case, etc. Under the Colorado Workers' Compensation Act, timeliness of prosecution is also a factor. Failure to take action to prosecute a claim for a period of 6 months will be considered failure to prosecute and may result in the closure of a claim. See C.R.S. 8-43-207(1)(n).
An order is a written decision by an Administrative Law Judge or the Director of the Division of Workers' Compensation that awards or denies benefits, imposes penalties, or directs the parties to take certain actions, such as close a claim, or respond to a request for information. An order will address a specific issue or issues which one or both parties have brought forward to be reviewed and decided. Certain orders, (those which award or deny benefits or impose penalties) may be appealed. If you disagree with an order that awards or denies benefits and wish to appeal, be sure to follow the instructions on the order and file your appeal (called a Petition to Review) exactly as described.
Individuals who lose more than three days or three shifts of work as the result of a work related injury or disease may be eligible to receive a form of wage replacement beginning on the forth day of work loss. This benefit is called temporary disability. Once started, temporary benefits must be paid every two weeks until terminated in accordance with the law. There are two types of temporary disability benefits:
temporary total disability?
Temporary total disability is a benefit that is available when an individual has been off work for more than three days or three shifts as the result of the injury. The benefit rate is based on two-thirds of the worker's average weekly wage at the time of injury up to a maximum established by law. The initial three days of work loss are not payable as compensation unless the injured worker is off for more than two weeks.
Temporary partial disability is a benefit that is available for partial wage loss when an individual has returned to work at less than full wages. Benefits are calculated at two-thirds of the difference between the worker's average weekly wage at the time of injury and his/her current earnings.
Temporary disability benefits will terminate when:
- You return to work at your pre-injury wage
- You are given a release to return to your regular work by your authorized treating doctor
- You are given written release by your authorized treating doctor to return to modified work, your employer makes you a written offer of such work, and you fail or refuse to begin the work*. You are allowed 3 business days to return to work in response to an offer of modified duty employment.
- You fail to appear at a rescheduled medical appointment following notification that such failure will result in suspension of temporary disability benefits.
- Your authorized treating doctor determines that you have reached maximum medical improvement (MMI). MMI means that the injury or disease causing your disability has become stable and no further medical treatment will improve the condition.
*If you work for a temporary help contracting firm, a business which hires people to work for a third party, you are entitled to receive only one written offer of modified work. Any future offers do not have to be in writing. The offer of work must be approved by your doctor. You are allowed at least twenty-four hours, not including Saturday, Sunday, or a legal holiday, to respond to the offer of work. If you do not accept the offer of work, your benefits may stop.
Temporary disability benefits may also be terminated by a petition. See What is...a Petition to Modify, Terminate or Suspend?
An insurance company may request permission to modify, terminate or suspend temporary disability benefits for reasons which fall outside of the standard criteria (see What is...the criteria for terminating temporary total disability benefits?) by filing a petition or request to terminate benefits with the Director of the Division of Workers' Compensation and stating the basis for the request. The form must be simultaneously filed with the injured worker and his or her attorney along with a response form. If the injured worker fails to object in writing within 20 days of the date of the petition, the request may be granted and benefits may be modified or terminated. If a timely objection is received, the insurance company must then set the matter for hearing before an administrative law judge or wait until benefits may be terminated under the standard criteria set by statute. See Rule 6, Suspension, Modification or Termination of Temporary Disability Benefits by a Petition.
"Maximum medical improvement" means a point in time when a physical or mental injury has become stable and when no further treatment is reasonably expected to improve the condition. The possibility that the condition may get better or worse over time or the fact that a person is receiving medical maintenance treatment does not affect a determination that s/he has reached maximum medical improvement.
Permanent partial disability means a permanent loss of function (or impairment) to a body part or a body system (i.e. nervous system, respiratory system, digestive system, etc.), that can be measured in accordance with The AMA Guide to the Evaluation of Permanent Impairment (Third Ed. Rev.) and which directly resulted from the injury or occupational disease. A physician trained (accredited) in evaluating impairment determines the amount of permanent impairment that has resulted from the injury or disease and assigns a number in the form of a percentage.
There are two types of permanent partial disability awards under the Colorado Workers' Compensation Act.
Scheduled Injuries: Permanent impairments to arms, legs, hands, feet, fingers, toes as well as vision and hearing are called 'scheduled injuries' because these injuries are compensated based on a schedule. The schedule can be found at C.R.S. 8-42-107 (2) and assigns a value to each of these body parts. The value is expressed in weeks. For example, the little finger of the hand is assigned a value of 9 weeks. To determine the amount of an award to the little finger, 9 weeks will be multiplied by the percentage of impairment (or loss of function) the physician determines has resulted from the injury. This amount is then multiplied by the compensation rate in effect at the time of the injury. For example, if the physician determines you suffered a 50% permanent impairment to your little finger, 50% of 9 weeks equals 4 ½ weeks. If the injury occurred between July 1, 2003 and June 30, 2004, when the weekly compensation rate for scheduled injuries was $207.35, then the award would be calculated in the following manner:
$207.35 x 4.5 weeks = $933.08
In another example, the physician has determined that as the result of an injury to your foot, you have sustained 10% permanent impairment to the whole foot. The injury occurred in August, 2004 when the compensation rate for scheduled injuries was $212.32 per week. The value of a foot below the ankle on the schedule is 104 weeks. Since impairment of the foot was rated at 10%, then 104 x 10% = 10.4 weeks and the permanent partial disability award is calculated as follows:
$212.32 x 10.4 weeks = $2208.13
Non-Scheduled Injuries: Permanent impairment to parts of the body or body systems that are not listed on the schedule are called 'non-scheduled injuries.' These include such areas as the spine, brain, lungs and mental function. The method for calculating awards for non-scheduled injuries can be found at C.R.S. 8-42-108 (8) (d). Non-scheduled awards are determined by multiplying the following four factors: 1) the medical impairment rating assigned by the physician, 2) an age factor which takes into account the injured worker's age on the date of maximum medical improvement (see chart at C.R.S. 8-42-108 (8) (e), 3) a fixed factor of 400 weeks, and 4) the temporary total disability rate.
For example, in a back injury claim, the physician has assigned 10% impairment as the result of a work related injury. The injured worker (claimant) is fifty years old and his temporary total disability rate is $200.00 per week. The award would be calculated as follows:
10% x 1.20 (age factor for 50 years) x 400 (weeks) x $200 = $9600.00
Permanent total disability means the employee is unable to earn any wages in the same or other employment. Like temporary total disability, these benefits are based on two-thirds of the average weekly wage in effect at the time of injury. Unlike temporary disability benefits, permanent total disability is paid for the lifetime of the injured worker.
A prehearing conference is an informal hearing conducted by an administrative law judge upon request of one of the parties. The judge may order the parties to attend. A prehearing conference provides an opportunity for the parties to a claim to meet and discuss issues and concerns about the case before a judge. The judge may also order the parties to exchange information, such as employment records, that may assist in resolving the issues.
A settlement conference before an administrative law judge may also be requested. All parties must agree to the conference. The judge will facilitate discussion and possible resolution of some or all of the issues. In a settlement conference, the judge must maintain confidentiality of all conversations or proceedings.
The Division of Workers' Compensation also is a resource for information regarding options for arbitration before an administrative law judge. These conferences may be scheduled in Denver, Boulder, Colorado Springs, Durango, Fort Collins, Glenwood Springs, Grand Junction, Greeley or Pueblo. Anyone needing further information about mediation services, prehearing conferences, settlement conferences or arbitration should call the Customer Service Unit.
A hearing is a formal legal proceeding where an administrative law judge decides what benefits, if any, must be paid, and decides any other issues. All parties may present evidence, including documents and sworn testimony of witnesses. A court reporter makes a record of the hearing. There is no jury. There is no charge for the hearing. Your failure to attend may result in an unfavorable decision, a delay in a decision on your claim, or the dismissal of your claim.
To request a hearing, you must file an Application for Hearing with the Office of Administrative Courts and send a copy to the insurance company. You may request this form by calling the Adjudication Docket. If you qualify for an expedited hearing, your hearing will be scheduled within 45 days of the date of the application. All other hearings are scheduled within 80-100 days. Office of Administrative Courts has two docket offices, one in Denver and one in Grand Junction. You may ask for a hearing in Denver, Boulder, Colorado Springs, Durango, Fort Collins, Glenwood Springs, Grand Junction, Greeley or Pueblo. Call the Office of Administrative Courts docket section for current information on locations.