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Resolving a worker’s compensation dispute

On Behalf of | Jan 6, 2021 | Workers' Compensation |

Some states use private insurance companies to provide workers’ compensation plans to employers. But in Connecticut, the Department of Administrative Services administers all workers’ compensation claims against the state’s self-insurance policy.

This means that workers may not bring a lawsuit to seek compensation after a workers’ compensation dispute, but the DAS employs a third party to decide claims and then adjudicates disputes through hearings if the parties cannot come to an agreement.

Structure of Connecticut workers’ compensation

Unlike some states, Connecticut’s self-insurance model, which the Connecticut Workers’ Compensation Act of 1913 designed and upholds, means that the state is ultimately responsible for resolving claims after injuries in the workplace. The state has the obligation to maintain fiscal responsibility while also ensuring that employees receive the care and compensation they need after an injury.

The Act dictates that the state’s workers’ compensation program covers medical expenses and lost wages for both full- and part-time workers after a work-related injury.

The DAS performs this role through eight district offices around the state.

Disputes after denial

After an injury, workers should report the incident in detail to a supervisor as soon as possible. The supervisor will not only report the injury to the appropriate third party adjudicator, but he or she will also provide the worker with a list of the network medical providers. In an emergency, the worker should seek medical treatment as soon as possible and report the injury later, but do keep in mind that using an outside medical provider could jeopardize compensation through the program — as could waiting too long to report an injury.

Once the third-party administrator hears the claim, they will either accept or deny it. If they accept the claim, they will then help the worker negotiate and obtain sufficient compensation, medical care and assistance returning to work. If they deny the claim, workers have the right to dispute the decision.

The DAS will set up a hearing under the Workers’ Compensation Commission or series of hearings to resolve the dispute. There are five types of hearings for workers’ compensation disputes, but DAS can resolve 95% of claims with an informal discussion between the parties. More fundamental disagreements may need more intensive hearings and resolution processes.

In matters of dispute, the worker’s health insurance company may need to pay for medical treatment up front and seek reimbursal later.