Workers Compensation FAQs
What is workers’ compensation?
Whether the party responsible is the employee, employer, customer, coworker, or any third party related to the workplace, it does not matter who is at fault – if an employee becomes ill or injured due to the work or the work environment, they are automatically eligible for workers’ compensation. In return for these benefits, employees generally waive the right to sue an employer for damages.
Who pays workers’ compensation benefits?
What injuries are covered?
If you have suffered an accidental injury during the course of your employment it is very likely that you are entitled to workers’ compensation. Even if you have suffered this injury as the result of carelessness, you are likely to be eligible for benefits.
Some cases are as a general rule not covered by workers’ compensation. You (the employee) are held responsible for injuries arising outside of the workplace, or from such as:
Violating work/office policy
The use of illegal drugs or alcohol
Self-inflicted injuries (such as provoking or starting a fight)
Committing a crime
As a general rule, it is important to note that to be entitled to workers’ compensation you must be a victim, and not the cause of the accident.
Is a worker that sustains an injury on the job entitled to compensation for disfigurement?
Does workers’ compensation cover only injuries or does it also cover long-term problems and illnesses?
If you suffer an injury that is perhaps not caused by an accident – such as tripping and falling – you may still be covered by workers’ compensation. Injuries can be caused by sustained physical strain during a longer time period, and do not necessarily need to be caused by an accident.
For example, if you suffer from back problems due to repetitive misuse or if you suffer an illness or disease as the result of work conditions (such as lung disease or stress related heart problems), you may receive workers’ compensation for those conditions.
Are You Covered by Workers’ Compensation?
Although most workers are eligible for workers’ compensation, laws vary between states. Therefore, always check your applicable state laws to see whether or not the exclusions below apply to you:
Domestic employees in private homes
As a general rule, federal government employees are also excluded from workers’ compensation. They are however covered for benefits under federal law.
Some states do not require employers to carry workers’ compensation coverage if they have fewer than a particular number of employees (usually 3 to 5), but again this varies from state to state.
It is important to note that if you work for one of these above employers, a workers’ compensation program may not cover you.
Do I have to be injured at my workplace to be covered by workers’ compensation?
No. What matters is whether or not your injury is job-related. So, if you are running an errand for your employer or traveling on business, you are covered for workers’ compensation. You are even covered if you have an accident related injury during a work- or office-related social function.
What kind of benefits will I receive?
If you are injured in a job-related situation you are almost always entitled to 100% compensation for reasonable medical expenses, including such as first aid or emergency room services.
It is important to note that benefits paid through workers’ compensation are never extravagant. While the system offers replacement income and medical expense coverage, these can be modest. Sometimes you can also receive and vocational rehabilitation benefits, such as job replacement assistance or training.
Assuming you are in a situation where you are temporarily unable to work, you will most commonly receive around 2/3 of your wages, up to a fixed limit (check with the state you live in). Your payments are tax-free; meaning that you may feel your compensation leaves you reasonably compensated (of course, depending on what the tax situation is in your state).
As soon as you are unable to work due to an injury or illness covered by workers’ compensation, you are eligible for your wage-loss benefits.
If you find yourself in a situation where you are unable to do the work that you could do prior to your injury, or are unable to work at all, you could be eligible for a long-term lump-sum benefit payment. This is only if you are permanently unable to work. How much compensation you will receive depends entirely on the kind and extent of your injury.
Processing times for workers’ compensation for permanent work disability benefits and payments are usually long, so it is advisable to contact your local workers’ compensation office as soon as you anticipate requiring their assistance. Read question 9 for more information on Social Security benefits for the permanently disabled.
If I am permanently disabled, will I be able to receive Social Security Benefits?
You may qualify for Social Security Disability benefits, should you find yourself unable to return to work permanently. While these benefits payments are usually higher than those of temporary benefits, they are also very difficult to process successfully.
Social Security benefits for the permanently disabled are as a general rule reserved for those workers who are seriously injured or ill as the result of an accident or long-term misuse.
In order to apply for benefits for being permanently disabled and unable to work, you should not be able to do any substantial work, and your injuries should be deemed to last for 12 months or more or even result in death if you were to return to work.
Contact your local Social Security office, if you have questions about your specific situation.
Can I be treated by my own doctor and, if not, can I trust a doctor provided by my employer?
If you have submitted a written request to see your own doctor in case of future injuries, you are allowed to do so in some states. It is more common however, that you will be referred to a doctor that your employer has hired and paid for.
The doctor’s report will make a big difference to the benefits you receive. If your employer (or his/her insurance company) has paid for your doctor, chances are that the doctor may not be your best friend in this process. For various reasons, your doctor may be motivated to minimize the severity of your injuries, or even suggest that you already suffered from your condition prior to working for that employer.
So, it is important to consider your answers when consulting a doctor who has been hired and paid for by your employer. Always answer truthfully, but also consider whether or not you should in fact detail any long-term medical history containing minor ailments – unless you have actually suffered a significant injury or had a chronic condition prior to your accident, the doctor may not require that information.
Most importantly, when you see a doctor for an injury that you believe is the result of a work-related accident, always give an accurate description of the accident as this will help substantiate your claim.
See the next question for information on seeing your own doctor after you see an insurance company doctor.
If I am initially treated by an insurance company doctor, do I have the right to see my own doctor at some point?
If your injury is serious, you normally have full rights to a second opinion. Also, if the insurance company doctor treats you for 90 days (or more), you can generally transfer your treatment to your own health plan or doctor while still under the coverage of your workers’ compensation insurance program. If you do so, it is advisable to see a specialist for your type of injury or illness – even if it is costly – since the insurance covers your medical expenses.
The rules in this area, when it comes to seeing a second doctor, can be complicated – the compensation systems vary between states across the country. Also, while you do have the right to demand a different doctor should you not approve of the one the insurance company provides, this may take plenty of time to achieve.
To be sure of exactly what your rights are, check with your local government rules or research your specific state compensation laws and regulations (usually found in the local law library).
Can I ever sue my employer in court over a work-related injury?
Yes you can. If you believe your injury comes from reckless or intentional action by your employer, you can sidestep your state’s workers’ compensation system and take your employer to court. You can sue for everything from punitive damages and pain to mental anguish.
It is always important to ask for legal advice on your particular situation before undertaking any court related process.
What if my employer tells me not to file a workers’ compensation claim or threatens to fire me if I do?
Unfortunately, this is not uncommon. However, in most states this is a violation of the law and employers can be held accountable for trying to retaliate against an employee who files a compensation claim.
Should your employer tell you that he/she would fire you in order to prevent you from filing a workers’ compensation claim, immediately report this to your local authorities or compensation office.
Are benefits payable to survivors of workers who have suffered death through a job-related accident?
Death benefits are generally paid to the widow(er) or the dependent children. Sometimes these benefits can be paid to other relatives if there are no other survivors. There can be a maximum death benefit, depending on your state and the laws there.
Does an injured worker have to let their employer know of a work-related injury?
Yes. You must report any accident to your employer or your foreman or supervisor (a superior who works for the same employer as you). Be sure to check within how many days from the accident (usually 45) that you need to notify your employer about the accident in person or in writing.
There are rules for how you should inform your employer. For example, notifying a co-worker who is not responsible for you is not considered proper notice – you must tell someone who is higher-up than you. Also, notify your employer about the accident as soon as possible, and do not – for any reason – delay informing your employer.
While it is good, if possible, to inform your employer of your accident in writing it is not required by law. What is very important, however, is that you do not under any circumstances sign a blank accident report form. Also, always remember to keep copies of any/all written material surrounding your accident.
Is an injured worker required to leave a recorded statement of the accident with their employer or the workers’ compensation insurance company?
No. This is not required in order for you to receive benefits. All your employer or workers’ compensation insurance company needs is proper notice of your accident plus the details of the doctor from whom you are receiving treatment.
It is important to remember that if a recorded statement – audio or video – is taken, it is not to the benefit of the injured worker. This recorded statement could on the contrary be used as evidence against you.
Is an injured worker required to cooperate with a rehabilitation process, nurse, or doctor as retained by the workers’ compensation insurance company?
Yes. If you fail to cooperate with the rehabilitation process you can have your benefits placed on hold or terminated by the insurance company.
It is important to note that any statements you make to a rehabilitation nurse or doctor are passed on to the insurance adjustor working on your case. Any offhand statements you make to the nurse or doctor can negatively affect your workers’ compensation claim.
What help is there for an injured worker that is not receiving the workers’ compensation they are entitled to?
If you have been injured at work and are being treated by a doctor who says you cannot return to your job because of your injuries, but are not receiving your benefits, you have the right to have your case heard before an arbitrator. At this hearing, you can present your medical evidence and ask your witnesses to show their support of your claim for workers’ compensation benefits.
Should you need to consider such a hearing, ask for help from an experienced and qualified workers’ compensation attorney. It is very likely that your employer or their insurance company will have an experienced attorney defending them – so it is important to be prepared.
When can an injured worker consider their workers’ compensation claim settled and closed?
You can consider your claim for workers’ compensation settled only after the settlement contracts are prepared and signed by everyone involved, and approved by the appropriate commission in your state.
After the above contracts are signed, you cannot claim additional benefits for those same injuries. Should you have a subsequent accident, you would need to file a new claim for workers’ compensation benefits.
Always ask for legal advice on your particular case, and consider what the statute of limitations is for your particular claim.