After I made make my request to reopen, what happens?
The insurer should respond within 30 days from the date they received both your request and the doctor’s report. You will be notified in writing of their determination regarding your application for reopening. An insurer may accept, accept in part, or deny your request for reopening. (NAC 616C.094)
Are all employees covered, including employees who are family members?
The short answer is yes. The specific definition of an employee can be found in NRS 616A.105. However, NRS 616A.110 carves out exceptions to the definition of an employee. For example, if you are a “casual” employee and not in the course of the trade, business, profession or occupation of his or her employer, you are not considered an employee and are not eligible for workers’ compensation benefits. Furthermore, NRS 616A.110 to NRS 616A.225 carve out specific requirements to be considered an employee in a specific trade or field.
Are there any maximum and minimum levels of compensation for the above outlined benefits?
Yes. Your maximum disability compensation (TTD) in Nevada is 66-2/3 percent of your average monthly wage See NRS 616A.065 and 616C.475.
For 2013 (July 1, 2012 – June 30, 2013), the maximum considered wage for this calculation is $5,222.63, which after multiplying by 66 2/3% yields a maximum monthly disability compensation of $3,481.75. There is no minimum payment for disability; however, NRS 616A.120 – 616A.205, inclusive, specify deemed wages for various types of volunteers, job trainees, county board members and others.
Please see the Division of Industrial Relations memo: http://dirweb.state.nv.us/WCS/MaxComp2013.pdf
Are there any Nevada state agencies involved with workers’ compensation and if so, how is my claim affected?
Yes, there are a number of state agencies involved in the workers’ compensation process:
- Nevada Division of Industrial Relations – http://dirweb.state.nv.us/wcs/wcs.htm
Is responsible for enforcing the Nevada workers’ compensation statutes and regulations
- The Nevada Division of Insurance – http://doi.nv.gov
Licenses, authorizes and certifies insurers, their agents and administrators.
- The Attorney General’s Fraud Unit
Investigates and prosecutes workers’ compensation fraud. Contact 1‐800‐266‐8688.
- The Hearings Division (HO / AO) – http://hearings.nv.gov/
This division is responsible for judging any appeal of a determination made by an insurer.
Are undocumented foreign workers covered under Nevada’s workers’ compensation statutes?
Yes. According to NRS 616A.105, any employee, including “aliens” that are legally or illegally employed are eligible for workers’ compensation. However, undocumented workers are not eligible for vocational rehabilitation.
Can I appeal a decision regarding claim closure?
If your reopening request is denied or accepted in part, you may appeal that determination to the Hearing Officer. You have 70 days from the date on the determination letter to appeal the determination.
Can I go to a doctor of my choosing?
No. Initially, in southern Nevada, your employer will likely send you to Concentra Medical Center. However, depending on your employment, it may be a different medical facility. Within 90 days of your injury, you may request a transfer of care under NRS 616C.090. If your claim is accepted your care may only be transferred to a medical provider on the insurer’s closed Panel of Treating Physicians and Chiropractors.
Do I have the right to reopen my claim in the future?
NRS 616C.390 details the requirements to reopen your claim.
An injured worker may be able to reopen their claim after it has been closed. However, not all claims may be reopened, generally if in your original claim, you were taken off work by a treating physician for any period of time or obtained a PPD greater than 0%, your claim may be reopened for life. If you are not taken off of work and you did receive a PPD greater than 0% you may only reopen your claim for 1 year following clam closure (NRS 616C.390(5)). Finally, if the insurer expended less than $300 in medical benefits on your claim, your claim may NOT be reopened (NRS 616C.235).
Lastly, in the rare occurrence that you were entitled to a Permanent Partial Disability rating and did not receive one, you may be able to reopen your claim if you weren’t given that benefit. (NRS 616C.392)
In order to reopen your claim, you must submit a written request to the insurer or self-insured employer requesting that your claim be reopened for medical treatment. You should include your claim number, name, social security number, date of injury, employer at the time of injury, and your current address and phone number.
A) Medical Evidence
In order to successfully reopen your claim it is your burden to provide medical evidence which justifies the reopening and the need for further medical treatment. You must provide medical evidence of three (3) things:
1. The primary source of the change in your condition is the original work injury.
2. Your condition has changed since your claim was closed as shown by
objective medical evidence.
3. You need further treatment to help improve your condition.
B) Doctor’s Note
In order to meet the above requirement you will be required to obtain a doctor’s letter which states the following:
1. Your condition has changed since claim closure.
2. You need treatment.
3. A description of the treatment.
4. That there is a direct relationship between your worsened condition at the time
you ask for reopening and your original injury.
5. Your work injury is the primary cause for your need to reopen your claim.
6. Any specified time period you are not to work at your job (the one you were
injured doing or the one you were retrained to do). (NRS 616C.390)
If you are trying to reopen your claim within one year of claim closure, you need to show the above points by clear and convincing evidence.
C) Cost of the Medical Expenses:
If the reopening is approved, you may be reimbursed the cost of emergency treatment, if you can provide sufficient evidence to substantiate that the treatment was necessary and done on an emergency basis.
Otherwise, costs of treatment which occurred in the time span between claim closure and reopening are not reimbursed. (NRS 616C.390(8))
Does an out‐of‐state company have to provide Nevada workers’ compensation insurance?
NRS 616B.600 describes the requirements of out-of state employers with workers in Nevada.
How do I file an appeal?
Generally, a determination letter from an insurance company will include a form to appeal that determination. However, it is your responsibility to appeal any determination which adversely affects your rights. The request for an appellate hearing must be made in writing and must include a copy of the determination letter or notice that is being appealed. If the decision letter is not included it may result in delays and/or possible dismissal of the appeal.
How is my average monthly wage determined?
Your average monthly wage (AMW) is a calculation which takes into consideration your provable earned income NAC 616C.420 – 616C.447, inclusive, provides details on all aspects of average monthly wage definition and calculation.
How long do I have to give notice and file a claim?
You have 7 days to fill out a C-1 form and give notice of your injury to your employer. Failure to properly file a C-1 form may cause your claim to be denied. Actual notice of your injury or ignorance of this filing requirement may be a defense to not filing the C-1 form, however, it is best not to take that chance and whenever possible a C-1 must be filed out and given to your employer.
You have 90 days from the date of injury or knowledge of the onset of an occupational disease to file a workers’ compensation claim (C-4 form). After that time, unless you can prove you were unable to file the C-4 because of an incapacity (e.g. in a coma) you have lost any right to workers’ compensation benefits and in this setting ignorance of the law is not a defense.
How long does it take before I find out if my claim has been accepted?
The insurer has 30 days after receipt of your C-4 Form to either accept or deny your claim. If your claim is accepted, the insurer will begin payment of the benefits you qualify for on the claim. If the insurer denies the claim, they must notify you and your representative of the denial. Claim denials must include your appeal rights.
I have been offered a light duty job; do I have to accept it?
If you reject a light duty offer made in accordance with NRS 616C.475 and NAC 616C.583 you risk the discontinuation of any TTD benefits you may be receiving.
I was injured at work, then my employer fired me, can he do that?
Nevada is an “employment-at-will” state. You may be terminated at any time, without any reason. However, you may not be fired solely for filing a workers’ compensation claim.
If I lose that appeal can I appeal to the AO level?
If you do not win at the Hearing Officer level, immediately appeal that decision to the Appeals Officer level within 30 days.
If my claim is not reopened how long till I can make another request to reopen?
When your claim is closed or your reopening request is denied, you cannot make another request to reopen until one (1) year has passed, absent unusual circumstances. (NRS 616C.390)
Is there a waiting period for workers’ compensation coverage?
No. From the moment you are hired you are covered by workers’ compensation
My employer is pressuring me to not file a workers’ compensation claim, can he do that?
No, but of course they sometimes do. Employers fear that their workers’ compensation insurance rates will go up if you file a claim. Regardless of their “pressure”, it is up to the insurer, not the employer (unless they are a self-insured employer), to accept or to deny a claim for workers’ compensation benefits.
What about if a third party injuries me while I’m on the job? Can I sue them?
Maybe. If a fellow employee as defined by NRS 616A.105 injuries you, then your “Exclusive Remedy” will be workers’ compensation. However, if a non-employee or person excluded from the definition of employee under 616A.110 injuries you, then you would be able to bring an action against that individual. Additionally, you would still be entitled to workers’ compensation benefits from your employer
What benefits are I entitled to from Workers’ Compensation?
You may be entitled to all or some of the following benefits:
- Medical treatment;
- Lost time compensation (TTD/TPD);
- Permanent Partial Disability (PPD);
- Permanent Total Disability (PTD);
- Vocational Rehabilitation;
- Dependent’s payments in the event of death; and
- Other claims-related benefits or expenses (i.e., mileage)
a) Medical Treatment: If you were injured on the job or have an occupational disease you may receive medical treatment for your injury. Any medical costs related to your industrial injury or occupational disease will be paid by your insurer. Typically, the physician or chiropractor is selected from a list of providers provided by your workers’ compensation insurer. However, you have the right to transfer your care to a provider off of the list within 90 days of the date of the accident.
b) Temporary Total Disability (TTD): This represents payment for your lost wages if your doctor certifies that you are unable to work for a period of at least 5 consecutive days, or 5 cumulative days in a 20-day period, or places restrictions on you that your employer does not accommodate. The compensation rate is 66-2/3% of your average monthly wage (AMW) with the average monthly wage being capped at a statutorily stated amount.
c) Temporary Partial Disability (TPD): If you are placed on restricted/modified duty and the your compensation rate or hours results in a pay rate of less than 66-2/3% of your AMW then the insurer may be required to pay you TPD compensation to make up the difference between what you are actually being paid per month and 66-2/3% of your AMW. TPD can only be paid for a maximum of 24 months.
d) Permanent Partial Disability (PPD): If at the end of your medical treatment your treating physician finds you are both stable and ratable, your insurer must arrange for an evaluation by a rating physician or chiropractor to determine the degree of your PPD. This must be done within 30 days. The amount of your PPD award is dependent on your AMW, age and the results of the percentage of your PPD.
e) Permanent Total Disability (PTD): If your treating physician certifies you as permanently and totally disabled and you have been granted PTD status by your insurer, you may receive monthly benefits not to exceed 66 2/3% of your AMW. This amount may be reduced if you previously received a PPD award on the same claim or body part.
f) Vocational Rehabilitation Services: After your medical treatment has concluded your treating physician may find that you have a permanent restriction as a result of your injury or occupational disease. If so, you may be entitled to vocational rehabilitation services, including but not limited to retraining for a job that meets your restrictions.
g) Transportation and Per Diem Reimbursement: You may be eligible for travel expenses and per diem associated with medical treatment. Please see the Department of Industrial relations letter regarding mileage and per diem. http://dirweb.state.nv.us/wcs/mileage.pdf http://dirweb.state.nv.us/wcs/lodging.pdf
What do I do if I get hurt on the job?
In the event of a serious injury, go directly to the nearest emergency room for treatment.
Generally, the following steps should be taken when injured on the job:
- Tell your supervisor immediately at the time of your injury or discovery of your occupational disease and ask to fill out the Notice of Injury or Occupational Disease incident report (C-1 Form). Fill this form out completely. Please make sure you sign and date the form. This form must be completed within 7 days of your injury.
- At the medical facility you receive your initial treatment, inform your doctor your injuries occurred on the job and you need to fill out a C-4 form (Employee’s Claim for Compensation/Report of Initial Treatment).Your worker’s compensation claim begins with the completion of that form. Fill out the top portion of the form completely; including the correct name, correct address and the correct phone number of your actual employer, the date of injury and your contact information. Missing, incomplete or inaccurate information will delay the process. After filling out the form completely, sign and date the C-4 and return it to the medical provider.
- The medical provider must complete the bottom portion of the C-4 as well as sign and date it. Within 3 working days, the medical provider will forward the C-4 to the insurer/TPA and employer. There is no claim until a C-4 form has been completed and filed with the correct claims administrator.
- Contact our office.
What if I disagree with the AO’s decision?
A party who disagrees with an Appeals Officer Decision may appeal that decision by filing a Petition for Judicial Review. This document is filed the Clark County District Court.
What if I don’t agree with an insurer’s decision?
If an injured worker does not agree with any part of a determination made by an insurer they may file an appeal and request a hearing.
You may contest an insurer’s determination in accordance with the provisions of NRS 616C.305 and 616C.315 to 616C.385, inclusive. There are 4 levels of appealing a determination by the insurer:
- File an appeal with the Hearing Officer(HO); If unsatisfied with the result,
- File an appeal with the Appeals Officer(AO); if unsatisfied with the result,
- File a Petition For Judicial Review with the District Court; If unsatisfied with the result,
- File a petition with the Supreme Court of Nevada. This appeal is the FINAL appeal available to you (unless your federal rights are implicated).
What if I need an interpreter?
At the initial hearing, the appealing party will usually be required to provide their own interpreter. However, if you need an interpreter for translation at subsequent hearings, you must notify the Hearings/Appellate Division of your need for assistance in writing prior to your hearing date. The interpreter is then provided and no cost to you however, if you do not show up then you will be charged for the interpreters services.
What if I retired from previous employment?
If you retired from your previous employment or voluntarily left your job for reasons unrelated to your injury before you file for reopening, you are entitled only to medical benefits; not lost wages. (NRS 616C.390(6))
NOTABLE WORKERS’COMPENSATION CASES IN NEVADA
|Spencer v. Harrah’s, Inc.||98 Nev. 99, 641 P.2d 481||(1982)|
|Leslie v. J.A. Tiberti Construction Co.||99 Nev. 494, 644 p.2d 963||(1983)|
|Imperial Palace v. Dawson||102 Nev. 88, 715 P.2d 1318||(1986)|
|Meers v. Haughton Elevator||101 Nev. 283, 701 P.2d 1006||(1985)|
|Breen v. Caesars Palace,||102 Nev. 79, 715 P.2d 1070||(1986)|
|SIIS v. Durable Developers,||102 Nev. 397, 724 P.2d 199||(1986)|
|Georgeff v. Sahara Hotel||103 Nev. 485, 745 P.2d 1142||(1987)|
|Holiday Inn Downtown v. Barnett||103 Nev. 60, 732 P.2d 1376||(1987)|
|SIIS v. Wren||104 Nev. 536, 762 P.2d 884||(1988)|
|Falline v. GNLV Corp.||107 Nev. 1004, 823 P.2d 888||(1991)|
|Shepcoff v. SIIS||109 Nev. 322, 846 P.2d 271||(1993)|
|Tighe v. Las Vegas Metropolitan Police Department||105 Nev. 440, 877 P.2d 1032||(1994)|
|Jerry’s Nugget v. Keith||111 Nev. 49, 888 P.2d 921||(1995)|
|Wyphoski v. Sparks Nugget, Inc.||112 Nev. 413, 915 P.2d 261||(1996)|
|Billmayer v. Newmont Gold Company||963 F.Supp. 938||(1996)|
|Browning v. Young Electric Sign Company||113 Nev. 420, 936 P.2d 322||(1997)|
|Bally’s Grand Hotel & Casino v. Reeves||113 Nev. 926, 948 P.2d 1200||(1997)|
|Tucker v. Action Equipment and Scaffold Company, Inc.||113 Nev. 1349, 951 P.2d 1027||(1997)|
|SIIS v. Ortega Concrete Pumping, Inc.||113 Nev. 1359, 951 P.2d 1033||(1997)|
|Hardy & Hardy v. Wills||114 Nev. 585, 958 P.2d 89||(1998)|
|SIIS v. Engel||_____________ 971 P.2d 793||(1998)|
|Roberts v. SIIS||114 Nev. 364, 956 P.2d 790||(1998)|
|Barrick Goldstrike Mine v. Peterson||116 Nev. 541, 2 P.3d 850||(2000)|
|Harris v. Rio Hotel & Casino, Inc.||117 Nev. 482, 25 P.3d 206||(2001)|
|Empire Insurance Company v. Chandler||117 Nev. 421, 23 P.3d 255||(2001)|
|Banegas v. State Industrial Insurance System||117 Nev. 222, 19 P.3d 245||(2001)|
|Tarango v. SIIS||117 Nev. 444, 25P.3d 175||(2001)|
|Construction Industry Workers’ Comp. Group v. Chalue,||119 Nev. 348, 74 P.3d 595||(2003)|
|Ayala v. Caesars Palace||119 Nev. 232, 71 P.3d 490||(2003)|
|Desert Valley Construction v. Hurley||120 Nev. 499, 96 P. 3d 739||(2004)|
|Day v. Washoe County School District||121 Nev. 387, 116 P.3d 68||(2005)|
|Mitchell v. Clark County School District||121 Nev. 179, 111 P.3d 1104||(2005)|
|St. Paul Fire and Marine Ins. Co. v. Employers Insurance Co. of Nevada||146 P. 3d 258, 122 Nev. Adv. Rep. 85||(2006)|
|Richards v. Republic Silver State Disposal, Inc.||122 Nev. 1213, 148 P.3d 684||(2006)|
|Seput v. Lacayo||______________134 P.3d 733||(2006)|
|Flamingo Hilton v. Gilbert||122 Nev. 1279, 148 P.3d 738||(2006)|
|Bero-Wachs v. Law Office of Logar & Pulver||123 Nev. 71, 157 P.3d 704||(2007)|
|Law Offices of Barry Levinson v. Milko||124 Nev. 355, 184 P.3d 378||(2008)|
|Dickenson v. American Medical Response||124 Nev. 460, 186 P.3d 878||(2008)|
|Vredenburg v. Sedgwick CMS and Flamingo Hilton-Laughlin||____________188 P.38 1084||(2008)|
|Bob Allen Masonry v. Murphy Workers Compensation||124 Nev. Adv. Op. No. 27||(2008)|
|Rio All Suite Hotel and Casino v. Phillips||126 Nev. Advance Opinion 34, 240 P.3d 2||(2010)|
|Sierra Nevada Administrators v. Negriev||128 Nev. Advanced Opinion 45, 285 P.3d 1056||(2012)|
|Williams v. United Parcel Services||129 Nev. Advance Opinion 41||(2013)|
|City of Las Vegas v. Evans||129 Nev. Advance Opinion 31||(2013)|
What if I’m just a part time employee, am I entitled to Workers’ compensation Benefits?
Yes, as long as you meet the requirements of NRS 616A.105.
What if my employer fails to obtain or maintain workers’ compensation insurance? Am I out of luck? Can I Sue them?
If an employer fails to obtain Workers’ Compensation insurance, they are subject to administrative fines and potential criminal liability and premium penalties and may be ordered to close business until insurance has been obtained and will be held financially responsible for all costs arising from a work-related injury. In addition, the uninsured employer may be subject to a criminal penalty for claims resulting in substantial bodily harm or death. (NRS 616D.200 & NAC 616D.345).
An employee’s only recourse in this situation is the Nevada Uninsured Employers’ Claim Account. See NRS 616A.430. The uninsured claim account acts in place of workers’ compensation insurance and pays some or all of your benefits. Therefore, it is important to remember to follow all of the requirements of filing and maintaining your worker’s compensation claim.
What is a de facto denial?
If an injured worker has written a letter making a request to an insurer or self-insured employer and that insurer has failed to respond to the injured worker’s written request within (30) days, the injured worker may appeal the insurer’s “failure to respond”. An injured worker has (70) days from the date of the insurer’s determination or the date the worker mailed the written request to the insurer, to request a hearing before the hearing officer.
What is the “Exclusive Remedy” rule, and why can’t I just sue my employer for my injuries?
In 1913 the Nevada legislature decided to protect Nevada employers from the uncertainty of lawsuits for damages suffered by their employees while on the job. Since that time, an employee’s “Exclusive Remedy” against their employer for any injury incurred while in the course and scope of their employment is workers’ compensation.
For more information, see the following memo by the Nevada Division of industrial Relations http://dirweb.state.nv.us/WCS/Handouts/exclrem.pdf
What is workers’ compensation?
Workers’ compensation is a no-fault insurance program which gives certain benefits to employees who are injured on the job while acting within the course and scope of their employment.
What occurs at the Appeals Officer (AO) level of appeal?
If you disagree with a Hearing Officer decision, you may appeal the Hearing Officer decision by completing a “Notice of Appeal and Request for Hearing Before the Appeals Officer” form and filing it with the Hearings Division within (30) days.
Generally, Appeals Officers conduct appeals of Hearing Officer decisions. However, there are some instances where a party can directly appeal a matter to an Appeals Officer.
Appeals Officer hearings are heard “on the record” which means that they are digitally recorded for purposes of providing transcripts of the proceeding in case of further appeals.
Appeals Officers will review the Hearing Officer decision, but they will conduct an entirely separate hearing, and the parties must separately submit the evidence they want the Appeals Officer to consider. The Appeals Officer does not consider the evidence submitted to the Hearing Officer unless it is submitted again, or unless a written request is made to admit the evidence previously submitted to the Hearing Officer.
The Appeals Officer can Affirm, Reverse, or Remand the Hearing Officer Decision or enter other orders allowed by law. The Appeals Officer must provide you with their decision within 30 days of your hearing.
What occurs at the Hearing Officer (HO) level of appeal?
All initial contested workers’ compensation claims are heard and decided at the Hearings Division by a Hearings Officer. A Hearing Officer’s authority and jurisdiction is limited to conducting initial administrative hearings for review of determinations made by an insurer. This is the initial level of review and is considered to be an informal process.
Each party should attend the hearing either in person or by telephone. However, you may forgo your appearance and submit your appeal position in writing. If a party does not appear or submit a position statement their appeal will be dismissed.
The Hearing Officer must provide you with a decision on you appeal with 30 days of the hearing.
Will I get a hearing on my appeal?
Initial hearings are scheduled within (5) days from the date the hearing request is received at the Hearings Division and are set within (30) days. All parties are given at least (15) days prior notice of the date of hearing.
Copies of all documentation to be submitted to the hearing officer must be provided to the opposing side.
Workers’ compensation has many deadlines, how do you compute the time?
Under the rules of the Nevada Administrative Code (NAC 616A.310) “In computing any period of time prescribed in chapters 616A to 616D, inclusive, of NAC, the day of the act from which the designated period begins to run must not be included. The last day of the period so computed must be included unless it is a Saturday, Sunday or legal holiday, and in that case, the period runs until the end of the next day which is not a Saturday, Sunday or legal holiday.