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The Role of the Employer’s Claims Advocate in Your Workers’ Comp Claim

A workers’ compensation claims advocate is a professional who specializes in helping employers manage their relationships with their workers’ comp insurance providers. Their most important role is to help the employer manage claims. For many employers, developing in-house expertise on claims processing is difficult or impractical, so they hire outside firms, often an insurance brokerage, to provide claims advocacy services. For the injured worker, a claims advocate can be a good resource and a significant help in the event that a claim is denied. At the same time, however, the employee needs to understand that the claims advocate’s job is to represent the employer, not the employee.

A claims advocate works with his or her clients to help them manage the costs of their workers’ compensation program. The idea behind the role is to help employers avoid expensive litigation arising from denied or mishandled insurance claims. An advocate may provide a wide range of services, from training employees on risk management to helping resolve conflicts with insurers. A claims advocate typically has an insider’s perspective on how insurers operate, and can sometimes resolve issues in a way that avoids more costly forms of intervention.

Employers often work with claims advocates as part of a broader investment in the welfare of their employees. As such, a claims advocate’s role is partly to help ensure that an injured employee gets the coverage they need. Employees can benefit from an advocate’s assistance in a number of distinct ways:

  • Ensuring that a claim satisfies legal and technical requirements.
  • Mediating between the injured employee, the employer, and the insurer to resolve disagreements.
  • Assisting the employer and employee to find solutions in the event that workers’ compensation won’t cover an injury.

On balance, services like these are of great benefit to an employee. But the employee always needs to remember that the advocate’s obligation is to the employer, not the employee. The advocate is there to help the employer save money by, among other things, reducing the risk of litigation. This motivation can result in a conflict of interest that may discourage the employee from pursuing the course that is in the employee’s best interest.

Working with an experienced workers’ compensation law firm is a good way for an injured employee to ensure that the claims process is handled with the employee’s interests in mind. 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.

Can a Nevada Workers’ Comp Claim be Reopened?

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.

Nevada law 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:

  1. Medical evidence demonstrates that an objective change in the claimant’s medical condition has taken place.
  2. 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:

  1. A change of circumstances (complications during recovery, discovery of previously undiagnosed problems, and so on) warrants an increase or rearrangement of compensation.
  2. The primary cause of the change of circumstances was the injury covered by the original claim.
  3. 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.