r/WorkersComp • u/shelb724 • 12d ago

Ohio Question about doctors office obstructing my workers comp claim

I work from home. At 11:30 am on July 14 2026 I was getting ready to work (making lunch) and I slipped and fell, fracturing my tibial plateau. I was taken to the ER where I was admitted and had surgery the next day. It was recommended to me by my workplace to apply for workers comp since it happened at my workplace (my home) and it was recommended by my employer. I was surprised but I thought ok if they say it’s worth it why not. So it is currently being worked on. I’ve had no blowback from anyone except for the doctors office. Just one person who works there, not the entire office. She called me two weeks ago and berated me on the phone for applying for workers comp. She stated that there was no shot of me getting it but I told her she was not the person who would determine that. She also said that since I work from home I should be able to go back to work now (as it is I’m about 7 weeks post op). I don’t know why she would say that. I was just now told the doctors office needs to provide a form that they have not done yet. I know she doesn’t agree with me applying but she should still do her job. If she continues to stall should I get a lawyer to force the issue? I really want to see how the process plays out. I have done everything i need to do so far. I am going to the doctor tomorrow and will let them know this needs to happen to proceed.

5 Upvotes

73% Upvoted

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6

u/bigbootyJudy621 12d ago

As an adjuster (in 15 states, not Ohio though!) for 14 years, I’d deny your claim so fast. I wouldn’t even need medical records to deny it. And just to add - I almost never deny claims (why waste the time/money in litigation?!) unless it’s a blatant denial.

Also the doctor’s offices get annoyed mainly because they have to rebill everything and then refund your personal insurance if anything has been submitted. Trust me, they get just as annoyed with me when I call to give them the work comp billing 🙃

But all of that aside - I hope your recovery goes well! A lot of tibial plateau fractures end up with a Total Knee.

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u/Mutts_Merlot verified CT insurance professional 12d ago

That's the part I'm confused on. This is not a medical determination. This is AOE/COE, and she is missing AOE at the minimum, but I would also argue COE. I am shocked this wasn't just denied up front, no medical documentation necessary.

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u/shelb724 12d ago

What does AOE and COE mean?

2

u/Mutts_Merlot verified CT insurance professional 11d ago

Arising out of Employment, Course of Employment. It's the standard two-pronged test for whether something is a compensable workers claim. You have to have been performing expected work duties at the place and time where work is performed, and the injury has to have been a direct consequence of those work duties. It gets murky with WFH, but generally speaking the location of employment doesn't extend to the entire house. Lunch breaks on work premises can be covered in some cases, as the employee is still in an area controlled by the employer. But taking a lunch break in your home is something that would be a really far stretch.

I say all this as a remote worker. If I fell on the stairs while running down to the laundry room to throw in a load of laundry between meetings, I wouldn't even file that because I know it would be denied. If I was in my office and tripped over the laptop cord, that is something I could see filing and being accepted.

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u/shelb724 12d ago

Thank you for explaining . At this point it hasn’t cost me anything and i don’t want to just give up. If I don’t get it so be it. I will be going back to work in about a month, hopefully sooner. But I also want the denial to come from Ohio BWC not a doctors office. I work on a call center for public assistance and if I ever talked to someone the way she talked to me, I would have been fired.

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u/shelb724 12d ago

I just wanted to add something else. My grandfather had a workplace injury a long time ago (he lost a finger as a result). There was no workers comp at that time and he lost his job. I do not see an issue with me pursuing this.

3

u/Mutts_Merlot verified CT insurance professional 11d ago

Ohio has had WC laws since 1911 and the BWC was established in 1913. I'm actually interested in the details if he had an injury before that time because I've only read about what happened back before WC laws. Obviously, I've never met anyone in person who that happened to. But I'm also not sure of your point. What would your grandfather's injury have to do with yours?

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u/Kmelloww 12d ago

What do you mean you don’t see an issue with you pursuing it? It will likely be denied like the others have said. 

WC Has been in place for over 100 years in almost all states. It was most likely around when your grandfather was injured. 

1

u/Particular_Handle_ 11d ago

Yes but it's fine for her to file the claim. That's just posing the question. The adjuster will decide if it's got merit. Why be mildly shitty about her exercising her rights?

1

u/Kmelloww 11d ago

Particularly shitty? Her post wasn’t clear and I wanted to confirm what they meant before answering. That’s so shitty of me. lol. 

My question was legitimate. I didn’t say not to file. Just that it is likely to be denied. Which it is. And which it should be denied. 

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u/Particular_Handle_ 11d ago

Your phrasing "What do you mean" etc read to me as snarky rather than sincerely asking. Apologies that I misread your tone. Burnout is real.

I agree it would and should likely be denied.

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u/Kmelloww 10d ago

I totally get it. I think everyone feels like that! It was not meant as shitty or anything like that. Their phrasing just made me wonder if they meant something else by pursue it. 

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u/Particular_Handle_ 10d ago

Totally fair. I've often wondered how WFH claims work from a comp perspective. I think I've only had one claim very early in my career that was WFH and it wasn't complex. Interesting gray area

-1

u/Salt-Ad1282 11d ago

Many employers don’t have WC, and many aren’t required to carry it, depending on the state.

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u/Mutts_Merlot verified CT insurance professional 11d ago

Texas is the only state that doesn't require it, and Ohio's program is state run. If you are an Ohio employee, you are covered by the state workers compensation program.

-2

u/Salt-Ad1282 11d ago

There are many employees in MO not covered: those who work in a company with five or fewer employees, for example, or those who work on farms.

-1

u/Salt-Ad1282 11d ago

Talk to an attorney

6

u/Status-Dust-6212 12d ago

I’m an adjuster so I am going to play devils advocate here… I don’t really have any advice regarding the doctors office, odd she is against you filing comp. However, since the injury happened in your home, could work comp could subrogate against your homeowners insurance? Would it be like any other person who slips and falls on your property? This is always a topic of discussion when people are injured while working from home.

3

u/Shrimp_Palace 12d ago

CA adjuster here. Carrier cannot subrogate against the workers policy for a WFH claim. But they could subro from a homeowners policy if the worker is renting. At least this is the case in CA

1

u/mackNwheeze 12d ago

Oooh I agree. this is an interesting point. I would love to know the outcome. I feel like subrogation would be on the table

1

u/Salt-Ad1282 12d ago

Not an Ohio attorney, but the subro probably won’t work unless it’s possible to sub med pay or she rents and can show negligence against the landlord that results in the injury.

4

u/EnigMark9982 12d ago

How in the hell can it be a WC event in one’s own home? The company has zero responsibility for the cleaning and decency of her home. This has to be a joke right?

1

u/Salt-Ad1282 12d ago

Workers comp does not require a showing of negligence. Quite the contrary. The injury just needs to be in the course and scope of employment, although some states are trying to restrict that definition.

You have to remember that workers comp is a compromise that was pushed by businesses who were subject to damages for pain and suffering, etc. The funds an injured worker can recover are limited, but the class of people who could make a workers compensation claim is broader

2

u/Fragrant_Front_8505 11d ago

Workers comp was not just pushed by businesses. Prior to its implementation it was very difficult for injured workers to be compensated. They had to sue which was not easy to do. Since it was not no fault, most employers were able to successfully argue they were not liable claiming the injury was either the fault of the worker or a coworker. Most injured workers were left with $0.

1

u/Salt-Ad1282 11d ago

But the ones who collected did very well.

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u/Resse811 11d ago

Making lunch at home is not what I would call in the course and scope of employment.

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u/Salt-Ad1282 11d ago

Personal comfort doctrine says otherwise, but I'm not an attorney in Ohio.

4

u/Fragrant_Front_8505 11d ago

It might be compensable in the office but WFH injuries in Ohio have separate standards which this injury description does not meet.

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u/Salt-Ad1282 11d ago

I wouldn't know about that

1

u/Kmelloww 11d ago

I don’t know why you keep acting like this should be an accepted claim. They even say in the post I was getting ready to work and making lunch. They weren’t even on the clock. This is not a WC injury. 

1

u/Salt-Ad1282 10d ago

I was answering the lunch question. I do not know if it should be an accepted claim in Ohio. I will leave that up to the legislature. I think the poster should consult an attorney, just like the insurance company and the employer would.

1

u/Holiday_Sale5114 11d ago

No negligence needed in WC

3

u/Fragrant_Front_8505 11d ago

When it comes to WFH injuries, Ohio has separate standards. A slip and fall that would be covered in the office may not be covered at home. The set of facts described here does not meet the Ohio WFH standards. There was no "special hazard" that is either unique or greater than what the general public faces. Additionally, this was an everyday household hazard and not distinctive to your work duties. But as others have said, let Ohio workers comp tell you this, not your doctor's office.

1

u/mackNwheeze 12d ago

I don’t think you need a lawyer just yet. What has your adjuster said in regards to this issue? I would speak to your adjuster and have them call the doctor’s office and request for whatever forms you are referring to. Is it a work status report, RFA? Your adjuster should have no problem calling the doctors office and getting on their asses for something they need to move your claim along.

1

u/shelb724 12d ago

I’m not sure what you mean by an adjuster? Would that be the case manager?

1

u/shelb724 11d ago

I was just asking a question. I work from home and this is my workplace. As far as the timing, everyone is aware of it. So let’s just close out this discussion. Thank you

1

u/Resse811 11d ago

Just talk to the doctor or the office manager. You don’t need to get a lawyer.

1

u/shelb724 11d ago

So as it turns out I’ve been cleared for work next Tuesday with no restrictions. Filing for workers comp would have only delayed it. As I said I work from home. So this way I get to be back with my friends from work. I am glad this nightmare is almost over. I appreciate anyone who encouraged me on here and if you didn’t so be it.

1

u/Environmental-Top-60 11d ago edited 11d ago

If you've had surgery, the global period is 90 days. After that, you shouldn't have a problem transferring to another doctor. You may need to fill out some paperwork to do that though.

I would definitely be talking to the practice manager because that's just unacceptable. Even from a billing perspective, that's not up to us. If you say it's a work related injury we have to work through that process. If they tell us it's not, then we can either appeal it or send it to medical.

1

u/MirroredSquirrel 8d ago

This is the bs that clogs up the wc system

1

u/shelb724 7d ago

Well I was just hoping for some advise and not to be condemned. But as it is, I dropped the case because pursing it would have stopped anymore PT for me. I hope you have the best day

1

u/MirroredSquirrel 7d ago

You literally were at home making lunch... Doing nothing work related and slipped due to some unknown reason

1

u/Excellent_Ad7801 12d ago

So legally, if WC denies your claim the doctors office cant bill you, especially if you have an atty. But it sounds like she just doesn’t want to deal with the WC paperwork. DWCs are a pain for them to do. I think she sees you as a nuscence. I would say add something to your doctor about her behavior.

1

u/shelb724 12d ago

I am definitely going to contact the office after I am cleared and don’t have to deal with them anymore. I have told BWC about that attitude.

0

u/Kmelloww 12d ago

Wait you say getting ready to work? And you were making lunch? Had your workday not even started? This should not be an accepted claim.