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Workers’ compensation makes benefits available regardless of fault, but this does not always mean that the process goes smoothly. The Workers’ Compensation Law Center provided by Justia describes what to expect and consider in these situations.
When someone gets injured on the job, they may need significant treatment and may miss time from work while they recover. The workers’ compensation system aims to address these concerns by providing reimbursement for medical costs and partial replacement for lost wages. To get these benefits, an injured employee does not need to prove that their employer did anything wrong. Still, pursuing workers’ compensation is not always straightforward. The Workers’ Compensation Law Center at Justia provides insights on how the process unfolds. Here are some answers to basic questions that an injured worker might raise.
Who Is Covered by Workers’ Compensation?
An injured worker must be an employee, rather than an independent contractor, to qualify for these benefits. Even if a business labels a worker as an independent contractor, they still are considered an employee if they meet the definition of this term under state law. The employer must have workers’ compensation insurance, although almost all states require most employers to sign up for this coverage. The employee must not work in a field explicitly exempted from workers’ compensation, such as some agricultural or domestic work. Finally, the injury must have arisen from the employee’s work.
How Long Do I Have To Report an Injury?
A worker should report their injury to the employer as soon as possible, even if they are unsure about its severity. They may have about 30 days to submit the report, but the deadline is much shorter in some states, potentially around 10 days. Other states simply require reporting as soon as possible without stipulating a specific number of days. The deadline for reporting an injury should not be confused with the deadline for filing a workers’ compensation claim. An injured employee may have a year or more to file the claim.
Why Are Workers’ Compensation Claims Denied?
While some denials arise from minor issues like failing to submit required documentation, others involve more significant problems with the claim. An insurer might argue that the injury did not arise from the employee’s job duties, or that they did not meet the deadlines under state law for reporting the injury or filing the claim. Or the insurer might question whether the injury has affected the worker to the extent that they are alleging. A worker whose claim is denied may appeal the decision within the agency responsible for administering these benefits. Ultimately, they might pursue an appeal in state court.
How Will My Doctor Affect My Claim?
A doctor who treats an injured worker will diagnose their condition and determine their course of treatment. They may testify during proceedings related to the claim, in which their written reports also may play a key role. Input from the doctor may affect not only the medical benefits that a worker receives but also their wage replacement benefits. This is because the doctor will determine when the employee can go back to work and whether they will need to have restrictions on their job duties at that point. If an injury leaves the employee with permanent limitations, the doctor’s analysis of their condition may affect their access to permanent disability benefits and vocational rehabilitation.
What Is an Independent Medical Examination?
An insurer that is skeptical about the opinion of the doctor who treated an injured worker may ask for an independent medical examination as a second opinion. While these doctors are supposed to be neutral, they are retained by the insurer and thus may have an incentive to favor their position. The IME may address issues such as the cause of the injury, the diagnosis, the extent of the appropriate treatment, and how long the worker needs to be away from the job to recover. A claimant should review the report of the IME doctor and address any obvious inaccuracies with the doctor and the insurer.
Should I Take a Settlement for My Claim?
A lump sum settlement provides a worker with a single payment or a set of structured payments. This can allow them to get access to funds efficiently, but it does not make sense in every situation. A worker who has suffered serious or complex injuries may not want to accept a settlement that covers future medical costs because this might not account for all the treatment that they might eventually need. Before agreeing to a lump sum for these costs, they should think carefully about what the worst-case scenario would require. In some cases, a worker might be able to limit a settlement to wage replacement benefits.
Can I Get Benefits for an Accident While Commuting To Work?
Under the “going and coming rule,” you generally cannot get benefits for injuries that occurred while you were commuting to or from your workplace. You also likely cannot get benefits for an injury during a lunch break if you are away from your workplace. However, a worker might be able to get benefits in certain situations, such as when they were doing something for their employer during their commute or their lunch break. They likely will be covered if they get injured at a company-sponsored event outside the workplace, especially if the employer requires or strongly incentivizes attendance.
What Happens If an Insurer Breaks the Rules?
To minimize their costs, workers’ compensation insurers sometimes may unreasonably deny a claim, or unreasonably defend a denial during the appeals process. This means that a worker may not get benefits as soon as they should have. An insurer that acts in bad faith may be ordered to pay a penalty and interest on late payments. Penalties also may be applied when an insurer fails to make payments as required under a court order or settlement agreement, or if the insurer does not decide whether to accept or deny a claim within the legally specified deadline after receiving the report of the injury.
Can I Reopen a Claim To Get More Benefits?
You may be able to reopen your claim if your condition gets worse after the claim was closed. Certain other situations also may justify reopening the claim, such as an error by the court or fraud by the insurer. Reopening a claim that resulted in a settlement may be more challenging, since these agreements often provide for a full and final release of claims arising from the injury. Reopening a claim that was previously denied also may be difficult and may require presenting medical evidence that was not available at the time of the denial.
Can I Sue Someone Else for an Injury on the Job?
Although an employee rarely can sue an employer or a coworker, they may be able to sue a third party that caused an injury while they were on the job. For example, perhaps a careless driver hit them, or perhaps they used a defective product. A third-party claim can allow an injured employee to recover more compensation, such as the full amount of their lost income and damages for pain and suffering. However, this would require proving the fault of the defendant, whereas access to workers’ compensation does not hinge on proving fault.
Final Thoughts
Laws governing the workers’ compensation system may be highly technical and vary from state to state. Justia provides a 50-state survey of workers’ compensation laws that describes some of these nuances, such as deadlines for reporting an injury, waiting periods for receiving benefits, and amounts available for wage replacement. Someone pursuing a claim should consider working with a lawyer, especially if their injury is serious or if its connection to their job is not obvious. An attorney also can advise them on whether they should bring claims against third parties. In the meantime, the Workers’ Compensation Law Center offers a readable overview of some key concepts in this area. Like the other Justia Legal Guides, it furthers our mission of making the law free and accessible to all.
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