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Claims FAQs

Below are some common questions that arise when a work injury occurs.
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Frequently asked questions

Below are some common questions that arise when a work injury occurs. For more detailed answers or to discuss specific details of an injury or claim, please contact your Pinnacol claims representative (303) 361-4000.

What should I do if I question whether my employee was injured while at work?
Any time an employee tells you that he or she had an injury at work, you must report it to Pinnacol as soon as possible, preferably within 24 hours. The sooner we know about the alleged incident, the better we can investigate it and gather complete information.

If the claim is not reported to us immediately, critical evidence and information may be lost. Your company may also be fined by the Division of Workers’ Compensation for not reporting an injury.

What if my employee reports an injury, but thinks he or she is all right and doesn’t want to go to the doctor?
We highly recommend you offer medical care to your employee and advise him/her to get treatment at one of your designated clinics or physicians. Be sure to give your employee the Designated Provider List Notification Letter with the names and addresses of your designated medical providers.

Use your best judgment and consider the type of injury before allowing the employee to continue working without medical treatment. If in doubt, it is always best to refer your employee to your authorized treating physician for evaluation and treatment.

What happens if my employee isn’t obeying safety rules or is under the influence of drugs or alcohol and gets injured?
A 50 percent penalty of benefits, other than medical benefits, may be taken if your employee willfully violates a written and strictly enforced safety rule.

The same penalty applies if your employee is injured while intoxicated and the injury resulted from intoxication. However, neither of these circumstances forms a basis for denying a claim completely, and the penalty is taken from wage-loss and permanent impairment benefits, not medical benefits.

The burden is on the employer and the workers’ compensation carrier to prove that the employee willfully violated a known safety rule that is strictly enforced. The employer and workers’ compensation carrier must also prove intoxication.

It is important to notify your claims representative as soon as possible so that a thorough investigation can be done.

How long does the injured worker need to miss work before wage replacement benefits are paid?
The injured worker may be entitled to wage replacement benefits when he/she has missed more than three work shifts. Shifts can be unpaid hours, days or partial days.

Do the injured worker's medical benefits cover anything other than medical treatment?
Medical benefits also cover the injured worker's mileage to and from medical appointments. Additionally, if the injured worker needs an interpreter, Pinnacol may arrange and pay for those services.

Can injured workers access any of their own claim information online?
Pinnacol provides claim-related information directly to injured workers through a Web-based application. The online application provides 24/7 access to:

- The name and contact information of the designated Pinnacol claims representative and other key Pinnacol staff

- Information to help explain and navigate the workers’ compensation process

- Benefit check information, including payment details and the scheduled mailing date of subsequent checks

- Medical information, including bills, records and correspondence from medical providers

- Claim-related correspondence from Pinnacol

Access to the injured worker online application. Injured workers who prefer not to access information online can continue to contact Pinnacol by phone and email. Providing online access is only meant as an additional convenience.

What happens if my employee is offered modified duty but still doesn’t resume work? Or what if the employee comes back and then needs to go home because of excessive pain?
If you offer your employee modified duty but he or she does not come back to work, call your Pinnacol claims representative or Return to Work™ Consultant for assistance in completing a formal modified-duty job offer.

If your employee comes backto work but then indicates that he or she is unable to continue, you should have your employee see the doctor to be examined rather than go home. The doctor will determine if your employee is able to perform the modified duty.

You should also contact your Pinnacol claims representative or Return to Work Consultant for assistance, as you may need to complete a formal modified-duty job offer. For details about this process, contact your claims representative or Return to Work Consultant, or refer to our Return to Work consulting resources.

With today’s HIPAA regulations, can I get information about my injured employee from the doctor?
Yes. HIPAA does not apply to workers’ compensation.

As the employer, you are allowed to obtain medical information and records about the workers’ compensation injury only. To that end, you should arrange for your designated physicians to fax your injured worker's Work Status Report to you after each appointment.

If additional medical information is needed, you should contact your claims representative.

What happens if my employee hires an attorney?
The fact that an employee hires an attorney for a workers’ compensation claim has no impact on the employer-employee relationship, nor does it necessarily mean your employee is suing you. Keep in mind that the hiring of an attorney does not change the benefits due to your employee under the Workers’ Compensation Act.

Why is my employee receiving wage replacement benefits when the employee no longer works for me?
If the doctor has given restrictions that preclude your employee from performing his or her regular job, and you are unable to provide modified duty within those restrictions, your employee may be entitled to wage replacement benefits until the point of maximum medical improvement.

Even if the employee no longer works for you, in most circumstances he or she would be entitled to wage replacement benefits if the restrictions keep that individual from being able to earn wages from another employer.

What if my employee is in a car accident while working, but the other driver is at fault? Do I need to report the injury under workers’ compensation?
You must always report the accident, even if the other party is at fault. Your employee may be entitled to workers’ comp benefits. If benefits are paid, then a request for reimbursement from the responsible party’s automobile liability carrier will be sought.

I have a deductible on my policy. Should I report the claim if I think the costs would be under my deductible?
Yes. You should always report every accident.

After Pinnacol makes payments for either medical or wage replacement benefits, we will request reimbursement from you for the payments that are within your deductible. You should not pay the bills yourself.

When Pinnacol pays medical bills, the billed amounts may be reduced by the Workers’ Compensation Fee Schedule and our preferred-provider contracts. It is likely that our payments will be lower than the billed amounts, so the amount you would reimburse may also be lower.

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