Most states provide workers’ compensation programs to help those injured on the job and give employers incentives to reduce work-related injuries and illnesses.
Your employer should report any work-related injury or illness immediately; they will take the necessary steps and file a claim with their insurer.
The Law
Workers’ compensation is a no-fault system designed to compensate employees injured during employment activities, with immediate medical treatment and temporary income provided immediately upon injury as well as permanent partial and total disability benefits for any lasting injuries or illnesses related to the work-related activity. It aims to minimize employer liability while offering injured workers immediate care, temporary income benefits and full or partial disability payments should they become permanently disabled as a result.
Most states mandate employers purchase insurance for their employees; however, certain states allow businesses to opt in and avoid coverage altogether. Most large employers and most small business owners must purchase coverage; those who fail to do so could face serious repercussions including payments of claims out-of-pocket as well as loss of the right to conduct business in that state.
In order to qualify for workers’ comp benefits, an injury or illness must be directly connected with someone’s job – this includes both traumatic injuries, repetitive strain injuries, and occupational diseases like post-traumatic stress disorder. Therefore, it is crucial that any workplace accident be reported promptly in order for proper investigation.
People must coordinate their health care and workers’ comp claims to avoid potential conflicts of interest. Doctors paid by insurers may have financial incentives to minimize claim severity or identify preexisting conditions. Depending on state regulations, you may be able to switch treating doctors if you’re unhappy with who has been sent your way.
Eligibility
Workers injured in work-related accidents or who become sick due to breathing in toxic chemicals at work can claim workers’ compensation benefits. Employees must meet state reporting requirements when reporting an injury or illness and disability payments provided by workers’ comp can cover income lost as a result of injuries and sickness; benefits include medical bills paid directly by insurance, lost wages coverage, and funeral allowance payments should an employee die on the job.
Workers’ compensation coverage depends on whether a genuine employment relationship exists between an employee and employer. Most states mandate businesses with any number of employees carry coverage; small business owners and sole proprietors may opt out. Some states allow large, financially stable firms to self-insure by paying premiums directly themselves.
As part of their compensation agreement, injured workers agree to waive their right to sue their employers for negligence in exchange for receiving guaranteed payments from workers’ comp. Employers benefit from knowing they’re shielded from potentially costly negligence suits. Unfortunately, this agreement can sometimes be challenged and it’s crucial that injured workers understand the laws within their state before agreeing to one. Consulting an experienced workers’ comp attorney can be invaluable when facing off against an employer or insurance provider who attempts to deny coverage.
Filing a Claim
Though every state’s workers’ comp system differs slightly, each claim must follow certain steps. The first step involves an employee reporting work-related injuries or illnesses to their employer as soon as they become aware. Each state imposes different time limits; it is vitally important that employees report injuries or illnesses related to workers’ compensation as soon as possible.
Once an injury or illness has been reported, employers are required to file a First Report of Injury (FROI) with their insurer within seven days – either directly by filling out and providing their employee section, or by keeping copies for themselves and providing it directly. Employees should fill out and give this form directly to their employer; keeping a copy for themselves.
Step two is for an employee to seek medical care from a provider authorized by their employer, noting in their records that this treatment was for workers’ compensation injuries or illnesses. This information will enable the appropriate benefits such as income or death benefits based on average weekly wages (AWW).
Consult a workers’ compensation lawyer if the process seems complex or overwhelming. An experienced attorney will be able to address any potential issues while explaining the law as it relates to your unique case.
Appealing a Decision
If your claim for workers’ compensation benefits was denied by an insurer, injured workers may be eligible to appeal that decision. Working with an experienced lawyer increases their odds of success when making this type of appeal.
An insurance company may contest your claim for various reasons. They could disagree that you were injured during employment, the extent or compensation owed for said injuries are different, etc. Board employees acting as claims examiners/conciliators will typically try to settle these disputes before going before a workers’ compensation law judge for a hearing; should this prove unsuccessful then the hearing will proceed anyway.
After conducting a hearing, the judge will make their ruling and it will become final thirty days post-entry of a Compensation Order unless either you or your employer file an appeal with the Appeals Board within that timeframe.
If your appeal was denied by the Appeals Board, you may be eligible to appeal it before the state Supreme Court for review. As this can be a lengthy process, it is wise to contact an experienced attorney immediately as they can review any errors within the appeals board’s decision and assess if there is sufficient evidence that can overturn it.
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