In an ideal world every injury would have a predictable, consistent path to recovery, or at the very least a clearly defined range of potential harms. Of course, we don’t live in a perfect world. An injury can be misdiagnosed or underdiagnosed at preliminary medical appointments, or its treatment can lead to unexpected complications that require additional medical care or expensive drugs that weren’t part of the original plan. For someone who is receiving care under a workers’ compensation claim, these kinds of complications can require a claim to be reopened.
“Reopening” a workers’ compensation claim can be necessary if an insurer has formally indicated that its financial obligations with respect to it have been fulfilled—that is, the claim has been closed. Closing claims is one of the ways insurers manage the predictability of their costs: by closing a claim, the insurer knows with certainty how much it had to pay, and how much it needs to pass on to the employer. Reopening a claim therefore necessarily involves a degree of paperwork.
sets out specific procedures for when and how a workers’ compensation claim may be reopened. The specific procedure depends on how long the claim has been closed. For claims that have been closed less than one year, the insurer is only required to reopen the claim if:
- Medical evidence demonstrates that an objective change in the claimant’s medical condition has taken place.
- There is clear and convincing evidence that the claimant’s change in circumstances was primarily caused by the injury covered by the original claim.
A claim must
be reopened within one year of being closed if the claimant wasn’t forced off of work for at least five days
, and didn’t receive benefits for permanent partial disability. In other words, for relatively minor injuries workers have a shorter timeframe to reopen their claims.
To reopen a claim that has been closed for a year or more, the claimant must show three things:
- A change of circumstances (complications during recovery, discovery of previously undiagnosed problems, and so on) warrants an increase or rearrangement of compensation.
- The primary cause of the change of circumstances was the injury covered by the original claim.
- The claimant’s doctor has provided a certificate attesting to the change of circumstances.
Any effort to reopen a claim must be grounded in an assertion that the reopened claim remains completely related to the original claim. That is to say, the ongoing circumstances of the worker’s condition must relate to a job-related injury. If circumstances that were unrelated to the original claim have since intervened, the insurer will deny the request to reopen the claim.
If an insurer denies a request to reopen a claim it may be necessary to sue. It is always a good idea to consult with an attorney before starting the process of reopening a claim to reduce the likelihood that a request will be denied and to have a plan for contesting a denial. The law firm of Greenman Goldberg Raby Martinez has represented clients in workers’ compensation cases for over 45 years. For a free attorney consultation about your case call us at 702-388-4476 or through our contacts page