Workers’ Compensation

Workers’ Compensation

The necessity of explaining your accident and injuries in a workers’ compensation claim cannot be overstated. Although workers’ compensation is supposed to be similar to no fault for the benefit of injured workers, in practice employers and insurance companies  look for ways to deny claims and benefits. If not initially, later on when the worker’s health or injuries do not heal as fast the insurance thinks they should.

What is workers’ compensation?

Workers’ compensation insurance, often called “workers comp,” is a state-mandated program consisting of payments required by law to be made to an employee who is injured or disabled in connection with work. The federal government does offer its own workers’ compensation insurance for federal employees, but every individual state has its own workers’ compensation insurance program.

Be sure to check your own state’s workers’ compensation benefits laws by referring to the appropriate office in your state on the State Workers’ Compensation official page of the U.S. Department of Labor’s website. In most situations, injured employees receive workers’ compensation insurance, no matter who was at fault for the injury. Because these workers comp benefits act as a type of insurance, they preclude the employee from suing his or her employer for the injuries covered.

What types of incidents are and are not covered by workers’ compensation insurance?

Workers’ compensation insurance is even designed to cover injuries that result from employees’ or employers’ carelessness. The range of injuries and situations covered is broad, but there are limits. States can impose drug and alcohol testing on the injured employee, and can deny the employee workers’ compensation benefits if such tests show the employee was under the influence at the time of the injury.

Compensation may also be denied if the injuries were self-inflicted; where the employee was violating a law or company policy; and where the employee was not on the job at the time of the injury. In Virginia the employee has to be specific as to what caused the injury. In a recent case, an employee who fell off of a ladder while painting was denied benefits because he was unable to explain how the ladder fell.

What are the mechanics of injury?

It is important to identify the mechanics of injury because everything else flows from it. What are the mechanics of injury?  What was the body movement that resulted in the injury? What was the movement of your body when you injured it, twisting, bending, turning, lifting, pushing, etc. What did your body come in contact with that caused your injury? Your focus is on motion and contact.

What types of expenses does workers’ compensation insurance cover?

Although the payments are usually modest, workers’ compensation insurance covers medical care from the injury or illness replacement income costs for retraining compensation for any permanent injuries benefits to survivors of workers who are killed on the job Remember, though, that if a person collects workers’ compensation benefits, he or she cannot sue the employer. Additionally, workers’ compensation benefits do NOT cover pain and suffering.

Wage replacement is usually two/thirds of the worker’s average wage, but there is a fixed maximum amount that the benefits will not go over. That may seem modest, but note that these benefits are not taxed. So, as long as the employee was making a fair wage, he or she should have no major problems. The eligibility for wage replacement begins immediately after a few days of work are missed because of a particular injury or illness.

Does workers’ compensation insurance cover long-term and permanent injuries?

Yes. Workers’ compensation insurance is not limited to just incidental accidents. It also covers problems and illnesses that are developed over a long period of time of doing the same injurious activity–for example, carpal tunnel syndrome or back problems from some sort of repetitive movement. If the employee becomes permanently disabled from doing the job he or she was doing before the injury, he or she will probably be eligible for long-term or larger lump-sum benefits.

This amount is determined based on the nature and extent of the injuries. Permanent work disability benefits are complex and often take a long time to process, so be sure to contact your local workers’ compensation office as soon as you can. Permanently disabled employees may be eligible for social security benefits as well. These benefits would cover more expenses in the long run.

Social security benefits are much harder to get than workers’ compensation insurance, however, because they require the employee’s injury to prevent the employee from doing any substantial gainful work, and last at least twelve months or result in death. If you think you meet these requirements, contact your local Social Security Office for information about how to obtain these benefits.

Is it a Work-Related Injury?

A work-related injury is one that happened while you were doing something on behalf of your employer or otherwise in the course of employment. Most injuries that can be classified as work-related are those that occur at the workplace, but also may occur in company-owned trucks and other locations as long as the employee was doing something connected to his or her job.

This includes company parties and other social events sponsored by an employer, but not necessarily on company-owned property. Injuries compensable under workers’ compensation insurance can sometimes include those resulting from “horseplay” or other instances where employees may have been disregarding workplace safety rules.

State laws, and even courts within some states, remain divided on this issue. If an injury occurs during lunch break, it may be considered work-related if it happens at the company cafeteria, on other employer-owned grounds, or otherwise connected to the course of employment (for example, lunch with a client at a restaurant).

Additionally, an injury may be considered work-related if alcohol was involved if it was provided at a work-sponsored event; mental injuries (such as anxiety or depression) may be covered if they were sustained on the job or caused by the job; and a preexisting condition worsened during the course of employment may be covered.

What are the steps if I have a work-related injury?

The first step is to immediately notify your employer, preferably on the day it occurs. Although reporting the accidental injury on the day it occurred is not required, it is preferred. Otherwise, employers and insurance carriers may challenge the occurrence of the accident. If possible give notice in writing. If the employer asks you to fill out an incident report, make sure that you keep a copy.

The second step is to seek medical attention, preferably on the day it happens or shortly thereafter. Do this even if the injury is small. Seeking medical attention is necessary so your accident and injury are documented. In explaining the accident, make sure you give the mechanics of the injury.

The third step is to get a lawyer to assist you with filling out and filing the claim forms that all states require to process your claim. The state is the administrator of workers’ comp claims. The fourth step is to follow your doctor’s order. In Maryland and D.C., you can choose your own doctor. In Virginia you have to choose from a panel of three doctors that the employer and insurance company give you.

If you are not given a panel of doctors after a reasonable passage of time, you can choose your own doctor. You do not have to choose from a panel for injuries that require immediate medical care but you may have to choose from a panel for follow-up medical care.

What happens if my employer does not carry workers’ compensation insurance?

If your employer does not carry workers’ compensation insurance as required by state law, you still have options to seek compensation for your work-related injuries. First, you can file a claim with your state’s uninsured employer fund, if one exists; this fund is designed to provide benefits to injured employees whose employers failed to obtain insurance.

Second, you may have the right to sue your employer directly through a personal injury lawsuit, which could potentially result in compensation for medical expenses, lost wages, and even pain and suffering—damages typically not covered under standard workers’ compensation claims. Additionally, employers who fail to carry required insurance may face penalties, fines, or even criminal charges imposed by the state.

It’s important to report the lack of insurance to your state’s workers’ compensation board or appropriate regulatory agency promptly. Consulting with an experienced workers’ compensation attorney can help you navigate the complexities of your specific situation and ensure that your rights are protected throughout the process.

Can I choose my own doctor for treatment under workers’ compensation?

The ability to choose your own doctor under workers’ compensation varies by state. In some states, you have the right to select any qualified healthcare provider for your treatment. In others, you’re required to choose from a list of approved doctors provided by your employer or the insurance company.

For instance, as mentioned, Virginia requires employees to select from a panel of three doctors offered by the employer, while Maryland and the District of Columbia allow employees to choose their own physicians. If you fail to adhere to your state’s specific rules, the insurance company may refuse to pay for your medical treatment.

In emergency situations, you generally have the right to seek immediate medical attention from any provider, but follow-up care might need to align with state regulations. Understanding your state’s laws on this matter is crucial. Always communicate with your employer and the insurance company regarding your choice of doctor to avoid complications with your claim.

What is the statute of limitations for filing a workers’ compensation claim?

The statute of limitations for filing a workers’ compensation claim refers to the deadline by which you must file your claim to be eligible for benefits. This time frame varies by state but typically ranges from one to three years from the date of injury or the date you became aware of a work-related illness. Missing this deadline can result in the loss of your right to claim any benefits.

Some states have different deadlines for specific types of injuries, such as occupational diseases that develop over time. It’s important to report your injury to your employer as soon as possible, as many states also have separate, shorter deadlines for notifying employers—sometimes within 30 days or less.

Prompt reporting and filing help ensure that evidence is preserved and that you receive timely medical treatment. If you’re unsure about the deadlines applicable to your situation, consult your state’s workers’ compensation board or an experienced attorney to avoid jeopardizing your claim.

How does returning to work affect my workers’ compensation benefits?

Returning to work can impact your workers’ compensation benefits in several ways. If you return to your previous job at full capacity and wage, your wage replacement benefits will typically cease, although medical benefits may continue if you still require treatment.

If you return to work in a limited or light-duty capacity at a lower wage, you may be eligible for partial disability benefits to compensate for the difference in earnings. It’s important to follow your doctor’s recommendations regarding your ability to work; returning too soon or performing tasks beyond your restrictions can worsen your condition and affect your benefits.

Employers are often required to accommodate medical restrictions by providing modified duties. Failure to accept suitable work offered by your employer may result in a reduction or termination of your benefits. Communicate regularly with your employer and the insurance company about your work status, and keep detailed records of any correspondence. If disputes arise over your capacity to work or the accommodations provided, legal assistance may be necessary to protect your rights.