New Mexico Workers' Comp Claims: Eligibility, Filing, and Appeals

New Mexico employees who are injured at work have the right to payment for medical bills, lost wages, and permanent impairments resulting from their injuries.

By , Attorney

Updated January 7, 2019

The workers' compensation system in New Mexico is a no-fault system that compensates injured workers for medical bills, lost wages, and permanent impairments resulting from their injuries. To take advantage of these benefits, injured workers must follow certain procedures required by New Mexico law.

Who Is Eligible for Workers' Comp Benefits in New Mexico?

In New Mexico, private employers with three or more regular employees must carry workers' compensation insurance. Most employees at covered businesses are covered by workers' comp, but there are a few exceptions for employees engaged in certain types of work. For example, workers' comp in New Mexico does not cover farm workers, domestic workers, casual employees, or real estate salespersons who are paid on commission.

Workers' compensation covers all injuries or illnesses that happen in the course and scope of employment, including slip and fall accidents and illnesses developed from over time.

What Should I Do if I'm Injured at Work?

To receive workers' comp benefits, you must report your injury to your employer. You should do so as soon as possible, but no later than 15 days after your injury. Your claim for benefits may be denied if you fail to give notice and your employer does not already know about your injury. Once your employer has notice of your injury, it will notify its insurance company. The insurance company will then decide whether to accept or deny your claim.

How Do I Get Medical Treatment?

If you need emergency medical treatment, you can go to the nearest hospital or urgent care center. For non-emergency care, you will need to check with your employer first. In New Mexico, your employer can either select your treating doctor or allow you to see a doctor of your choosing. If your employer chooses the initial doctor, you can switch to your own doctor after 60 days. If you choose the initial doctor, your employer can select a new doctor after 60 days.

What Workers' Comp Benefits Can I Receive in New Mexico?

All reasonable and necessary medical treatment related to your work injury will be covered through workers' comp in New Mexico, including the cost of doctors' visits, hospital bills, prescriptions, and prosthetic devices. You'll also be reimbursed for the mileage you incur in traveling to and from medical appointments. In addition to medical benefits, you will also be eligible to receive disability benefits.

Temporary Disability Benefits

If you need time off from work while you are recovering from your injuries, you can receive temporary total disability benefits. These benefits are two-thirds of your average weekly wages, up to a maximum set by state law each year. For 2018, the weekly maximum is $796.96. You will receive these benefits until you are able to return to work or until your doctor finds that your condition has improved as much as it is going to (this is called "maximum medical improvement").

If you are able to work while recovering from your injury, but you're earning less than you normally do, you can receive temporary partial disability benefits. These benefits are two-thirds of the difference between your wages, subject to the same maximum mentioned above.

Permanent Disability Benefits

Once you reach maximum medical improvement (MMI), your doctor will evaluate you to determine whether you have a permanent disability. If your injury has left you permanently and totally disabled, you can receive permanent total disability benefits. These benefits are available only for the most serious injuries, such as serious brain injuries or the loss of both hands, arms, feet, legs, eyes (or a combination of any of two of these body parts). Permanent total disability benefits are paid at the same rate as temporary total disability benefits for the rest of the worker's life.

If you have a permanent impairment, but you are not totally disabled, you can receive permanent partial disability benefits. How much you will receive, and for how long, depends on whether your injury is listed in New Mexico's schedule of injuries.

New Mexico's schedule lists injuries to certain body parts—such as a hand, arm, leg, foot, finger, toe, eye, and ear—and designates a maximum number of weeks for which benefits are paid. For example, the schedule allows a worker to receive benefits for 160 weeks for the total loss of use of an arm at the elbow. If the worker has suffered only a 50% loss of use, he or she can receive benefits for 80 weeks. You will receive two-thirds of your average weekly wage during this time, subject to the same maximum as temporary disability benefits.

Injuries not listed on the schedule—such as those to the back or neck—are considered whole body impairments. Your benefit rate will depend on a number of factors, including your impairment rating, age, education, and the physical demands of your job. If your disability rating is 80% or higher, you will receive benefits for up to 700 weeks. If your disability rating is less than 80%, you will receive benefits for up to 500 weeks.

What If My Claim Is Denied?

If you would like assistance trying to resolve the dispute informally, you can contact the New Mexico Ombudsman Program at the Workers' Compensation Administration (WCA). An ombudsman is a representative from the workers' comp agency who can answer your questions and try to help you resolve minor disputes with the insurance company. If you're not able to resolve the dispute with the insurance company with the help of an ombudsman, you'll need to file a complaint with the WCA Court Clerk. To do so, you must file a complaint form and a summons with the court clerk and mail a copy to the insurance company. You must file your complaint within one year of the insurance company's refusal to pay your benefits.

In addition to filing a complaint, you will need to give a form to your doctor to fill out called the Form Letter to Health Care Provider. Your doctor must complete the form—which asks about your injury, treatment, and continuing limitations—and return it to the WCA Court Clerk.

Mediation Conference

Once the WCA receives your complaint, your case will be scheduled for a mediation conference. A mediation is an informal meeting, where a neutral third party from the WCA (called a "mediator") will try to help you and the insurance company reach an agreement. You should bring copies of documents that your support your case, including medical records, witness statements, unpaid medical bills, and wage records. The mediator will review these documents and ask you questions about your claim.

If you and the insurance company agree on a resolution, the mediator will write up the terms of the agreement. If you cannot agree, the mediator will make his or her own recommendation as to how the dispute should be resolved. Either party may reject the recommended resolution within 30 days. Otherwise, the recommendation becomes a binding court order.

Workers' Comp Hearing

If either you or the insurance company rejects the mediator's recommendation, you will continue on to a formal hearing before a workers' comp judge. Hearings usually take place within a few months of filing a complaint. You will receive a written notice in the mail, with the time and place of the hearing, at least 20 days in advance.

At the hearing, both sides will have an opportunity to submit documents, present testimony from witnesses, and make legal arguments. The judge will review the evidence and mail a written decision after the hearing.

Unlike in many other states, the New Mexico workers' compensation agency does not provide a second level of administrative review. Instead, if you are unhappy with the judge's decision, you must file an appeal with the New Mexico Court of Appeals within 30 days of the judge's order.

Getting Help With a Dispute or Settling Your Case

You can settle a dispute in your case by entering into a full and final agreement to take a lump sum payment in lieu of future benefits, including your right to future medical treatment. If there is no dispute, but you want to receive the rest of your weekly benefits in a lump sum, you can file a Petition for a Lump Sum Payment; however, this is allowed in only a few specific situations. The New Mexico Workers' Compensation Administration must approve all settlements.

While it's not a requirement, most workers with contested workers' compensation cases hire lawyers to represent them in the appeals process or to settle their case. Appealing or settling a claim requires detailed knowledge of workers' compensation law and procedural rules, especially when it comes to presenting your case at a workers' compensation hearing. Having a lawyer on your side can greatly increase your odds of success.

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