With most types of insurance, adjusters usually do what they are supposed to do. I know that’s not always true, but compared to workers’ compensation it is a general rule. For instance, if you get in a car wreck, your insurance will usually pay to fix your car without much of an argument. If your roof sustains hail damage, your homeowner’s insurance will usually pay for a new roof with little argument. But, get hurt at work and adjusters make up legal standards to deny benefits.

Adjusters make up legal standards to deny benefits in workers’ compensation cases at all stages of the claim. In this installment of our Games Insurance Companies Play series, I want to tell you about how an adjuster pulled this trick towards the end of a claim to try to take away an injured workers’ impairment income benefits. In our opinion, this adjuster tried to steal over $12,000.00 from the claimant.

The injured worker in this claim was a real estate agent who earned commissions for selling houses. Her average weekly wage was $4,238.00. That was her average weekly income before she got hurt. Because her injuries restricted her ability to walk and show houses, she was not able to earn her pre-injury wages so she was paid temporary income benefits.

Later in the claim the adjuster found out that the injured worker had earned some wages during the time period that temporary income benefits were paid that she didn’t know about. The adjuster’s response to that was to cut off all of the claimant’s impairment income benefits and pay the insurance company back for the benefits that had been paid while the claimant was working. Sounds fair, right?

Well, it’s not fair. The injured worker had been earning $4,238.00 per week before she got hurt, and then she had earned only about $1,200.00 per week during this time period that set the adjuster off. Her temporary income benefits had been paid at $1,100.00 per week, which was the max she could get by law. In the adjuster’s scheme, she declared that because the claimant was earning more than her weekly workers’ comp check, she wasn’t owed any of the money paid to her so the insurance company can take it all back out of her impairment income benefits. Sounds logical, right?

Division of Workers’ Compensation’s Rule

Well, It’s not logical. According to the Division of Workers’ Compensation’s Rule 129.3, an adjuster is supposed to compare a claimant’s weekly earnings to her average weekly wage (the pre-injury wages) and if her current earnings are less than her pre-injury wages, the adjuster has to pay her 70% of the difference up to the max allowed by law. In this instance, $4,238.00 (pre-injury wage) minus $1,200.00 (current earnings per week) is $3,038.00. Temporary Income Benefits are 70% of that, which is $2,126.00. So, this injured worker was still owed the maximum benefits allowed by law even though she had earned wages at another job!

The action that the adjuster took is a classic example of how insurance adjusters make up legal standards to deny benefits. This adjuster owed full temporary income benefits and found a way to tell the injured worker that she wasn’t owed anything at all. Many injured workers just believe what the insurance company tells them. Luckily, this worker sought the advice of an attorney.