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Workers’ Compensation Claims: Benefits for Work Related Injuries

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Find out how Workers Compensation Benefits can replace your lost wages and healthcare benefits if you’ve suffered a work-related accident or illness.

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Have you been injured and/or disabled on the job, in the workplace or while traveling on company business as part of your job? Did your employer’s working conditions cause or aggravate an illness? Are you a dependent of someone who recently died because of a work-related accident or illness?

If so, you may be eligible for Workers’ Compensation benefits — a lump sum or paid over time — eliminating the need for you to take legal action against your employer. Benefits will cover your medical expenses, prescriptions, physical therapy and more. It will also provide payment of a percentage of your lost wages. However, if your claim is contested or denied, legal services will be helpful to attain benefits, or if a third party was involved, legal assistance in suing them for damages.

Individuals working for private companies, or for state or local government agencies, can ask the Workers’ Compensation agency in their state for details regarding eligibility, assistance and filing procedures.

What Workers’ Compensation Is — And Isn’t
Workers’ Compensation is an insurance program that provides employers a means to bypass time-consuming, expensive lawsuits and speed payments to workers who are injured or develop work-related illnesses on the job.

Workers’ Compensation benefits ill and injured employees two ways: It provides coverage of medical expenses required to treat, heal or cure the work-related issue, and it pays a percentage of lost wages while the employee is not able to work.

Coverage details vary from state to state. In some states, companies with less than five employees are not required to have coverage. Many states exclude volunteers, farm workers and/or domestic workers from coverage.

Workers’ Compensation is not a program for the self-employed, independent contractors working for one or more customers/clients, those who own or are part-owners of a business, or so-called casual employees (e.g., those hired to remove snow or mow the lawn).

Even if the company you work for classifies you as an independent contractor, and therefore not eligible for Workers’ Compensation (and other) benefits, you may actually be considered an employee under the law. If you’re unsure about this, it might be wise consult with an attorney, and to file a claim anyway. Then it will be up to your employer to prove that you are legally an independent contractor, rather than an employee.

How Workers’ Compensation Differs From Social Security Disability Benefits
Under Workers’ Compensation, your disability must be work-related in order to receive benefits, which include coverage of your medical costs, prescriptions, rehabilitative therapy and other services that will help you get back to work as soon as possible. It also provides for you to receive a percentage of your wages while you are recuperating. If you are not expected to recuperate from your illness, Workers’ Compensation continues to pay for your medical care and a percentage of your lost wages. The insurance premiums are paid by your employer.

Under Social Security Disability Insurance (SSDI), your ailment or injury must be disabling to a point where you will not be able to work for at least 12 months, or if your condition is expected to result in death. If you qualify, SSDI provides a limited amount of income during that time. You may get medical assistance from Medicare if you qualify.

If you have paid premiums for Social Security coverage, usually through payroll deductions, and have enough credits (based on your income and amount of time worked), you may be eligible for Social Security Disability Insurance (SSDI) benefits — if you cannot work for at least 12 months due to an injury or illness. Temporary disability is not covered by SSDI.

It is possible for you to qualify for both SSDI and Workers’ Compensation at the same time, assuming your claims are valid and you meet the criteria. However, the total benefits you receive from both programs cannot be more than 80% of your average earnings prior to becoming injured or ill. If you receive Workers’ Compensation benefits, your SSDI benefits may be reduced accordingly.

Some states allow disabled workers to collect Workers’ Compensation benefits and unemployment benefits (if eligible) at the same time. To find out if this applies to you, file claims for both and they will let you know.

If you are also covered by a private disability insurance program—with you and/or your employer paying the premiums—you might also receive benefits from the private program even if you are receiving Workers’ Compensation benefits… unless the private program specifically excludes such benefits. Read the fine print of your policy or ask your employer for details.

A Brief History of Workers’ Compensation
During the second half of the 19th Century, as the United States became an industrial nation, an ever-increasing number of men, women and even young children were employed in factories, processing plants and other mass-production facilities (many with unsafe machinery, procedures, ventilation, etc.). As their numbers grew, so did the number of work-related injuries, illnesses and deaths…and the number of lawsuits seeking damages.

To reduce the need for litigation, while easing the requirement that injured workers had to prove that their injuries were the fault of their employers’ working conditions, Workers’ Compensation laws were enacted—first in Maryland in 1902, followed by Wisconsin in 1911, and then by the other states.

In general, Workers’ Compensation laws are a compromise. They guarantee medical care to injured workers, along with a measure of payment for lost wages, on a no-fault basis, without employees having to file lawsuits.

At the same time, they help employers avoid frequent lawsuits that could be disruptive and extremely costly, and place limits as to how much money or reimbursement their injured workers can receive.

In most states, employers obtain Workers’ Compensation coverage through private insurance companies, while in a few states this coverage is provided by a state government agency. The premiums that employers pay are based, in part, by their industry’s classification, with those in hazardous industries paying more than those in safer industries.

Only in Texas, employers are not required to have Workers’ Compensation insurance or self-insurance, but they can purchase coverage from private insurance companies.

Although the Workers’ Compensation program has proven to be very effective, there are challenges. There are the ever-increasing premiums for employers, and (at times) slow claims processing for employees. There is always the need to involve doctors to verify the claims, and attorneys hired to prove or disprove claims, to help injured workers obtain the benefits they’re entitled to, in the shortest possible time frame.

How Federal and Certain Other Employees Are Protected
Federal employees and certain other groups are not protected by individual states, but by these Workers’ Compensation programs of the U.S. government:

Federal Employees’ Compensation Act (FECA)
This act provides coverage to some 3 million federal and postal workers throughout the world, for job-related injuries and occupational diseases.

It also covers other employees of the United States (except those paid from non-appropriated funds), including the Peace Corps and VISTA volunteers; federal petit jurors and grand jurors; volunteer members of the Civil Air Patrol; Reserve Officer Training Corps cadets; Job Corps, Neighborhood Youth Corps, and Youth Conservation Corps enrollees; and non-federal law enforcement officers under certain circumstances involving crimes against the United States.

Benefits include wage replacement, payments for medical care, and (where necessary) medical and vocational rehabilitation assistance in returning to work.

For simple occupational illness cases, a decision may take up to 90 days, or as long as six months if it’s a complex case. For traumatic injuries, allow up to 45 days, or more if it’s complex.

Claims for loss of wages are usually handled within two or three weeks.

Energy Employees Occupational Illness Compensation Program
This program provides benefits to employees of the Department of Energy (DOE), its contractors or subcontractors, and atomic weapons employees who have radiation-induced cancer due to their worksite (under certain conditions).

Longshore and Harbor Workers’ Compensation Act (LHWCA)
This act provides medical benefits, compensation for lost wages, and rehabilitation services for longshoremen, harbor workers, and other maritime workers who are injured during the course of employment or who suffer from diseases caused or worsened by employment conditions.

Also covered are workers engaged in the extraction of natural resources of the outer continental shelf, employees on American defense bases, and workers under contract with the U.S. government for defense or public works projects outside of the continental United States.

Black Lung Benefits Act (BLB)
In cooperation with the relevant states, this act provides benefits to coal miners who are totally disabled due to pneumoconiosis, and to the surviving dependents of miners whose death was due to this disease.

Types of Claims: Injury • Occupational Illness • Death
Injury — When you think of a job-related injury, you probably picture a worker falling off a ladder, or being injured by some factory machine, or some other incident involving physical violence. These types of injuries—and far worse ones— take place all the time throughout the country, in workplaces of all types and sizes.

Work-related injuries may also be caused by repeated physical motions (e.g., lifting or carrying heavy cartons, tools or children), exposure to airborne chemicals or other fumes, psychological stress (e.g., constant harassment; coping with assembly line speeds), or other physical or mental hazards.

Generally speaking, Workers’ Compensation covers damages that occur in the course of employment at a worksite or while making service calls.

Since it’s a no-fault system, you may be covered even if the injury was due to your own carelessness, as long as your behavior was otherwise acceptable.

Occupational Illness — Any illness or disease can be classified as an occupational illness when job conditions increase the chances of suffering from that illness or disease. In some states, certain illnesses (e.g., heart attacks; hernias) are presumed to be covered for high-stress occupations (e.g., police officer; firefighter) if there is a direct connection between the work and the illness,

However, claims investigators from the insurance carriers may check to see if there are any non-work factors (e.g., drinking; smoking; poor diet; lack of exercise) that are present to negatively affect a particular condition, in an effort to weaken your claim that the illness was strictly work-related, and deny payments.

In recent years, the courts have increasingly recognized emotional illnesses, stress-related digestive problems, and other such illnesses as the gradual result of unhealthy work conditions and often consider them valid claims.

Prompt Medical Care, along with additional care if required, for a work-related injury or illness is usually covered by Workers’ Compensation. The question is: Who provides that care?

In most states, you are allowed to go to the doctor of your choosing, so long as they are authorized by the Workers’ Compensation Board. To protect your right to choose a doctor, some experts suggest that you send a letter to your employer (and keep a copy of it) informing them that if you are ever injured on the job, you would prefer to be treated by your regular doctor (unless emergency treatment is needed immediately). Otherwise, they say, your employer or their insurance company may have you examined by a doctor of their choice, who might provide a conservative diagnosis of your injury, thereby jeopardizing your Workers’ Compensation claim.

Therefore, if you are treated by a doctor chosen by your employer or their insurance company, get a second opinion from your own doctor, even if you have to cover the cost yourself. Even if you go to an approved doctor of your own choosing, the insurance company may ask you to go for an Independent Medical Examination. You are trying to get the best possible care, but you also need to document your condition to prove your injury occurred while working or you illness was caused by your work conditions. Even if you are not terribly hurting immediately after an accident, or at the time of your diagnosis, your condition may worsen over time.

If your claim is approved, the insurance company would be responsible for all related medical expenses.

Death — Almost always, when employees are killed on the job due to a work injury or illness, their spouse, children or other dependents are eligible to receive Workers’ Compensation benefits. Rarely do the courts consider the possibility of murder or suicide, unless there is evidence suggesting it as the cause.

How to File a Claim to Collect Your Benefits
If you suffer a work-related injury or illness, you should first get immediate medical care if required to treat it. Next, notify your employer, verbally and in writing. If you are a member of a Union, notify them as well. Depending on the state where your injury or illness occurred, notification should take place within a few days or weeks. (In a few states you must file within two years.) It is recommended that you file an Accident Report with your employer and put in your Workers’ Compensation claim as soon as possible, as this may make it easier to verify your injury or illness is work-related.

Most states require companies to post Workers’ Compensation claims procedures in a common area for all to see. Obtain Workers’ Compensation claim forms from your employer to fill out and submit if they have them on hand. If not, you can obtain them from the Workers’ Compensation agency in the state where your accident or illness occurred — not the state where you live, if different. Depending on the state, you may also need to submit a copy of the Workers’ Compensation claim form to your employer, to the state agency, or to both. The sooner you file, the better.

If your employer or their insurance carrier does not dispute your claim, it will be approved. Next, an insurance adjuster or your employer will provide instructions on how to submit your medical bills for payment or reimbursement.

Typically, you would be covered for the cost of doctors, nurses (including home care if necessary), hospitals or clinics, physical therapy, medical supplies, dental care, chiropractic care, prosthetic devices — whatever may be required.

If you suffered a temporary injury, with no loss of income, those bills will be paid promptly (in most cases). Should you be unable to work because of your injury, also expect to receive payments to cover some or all of your lost wages.

If you are expected to recover and go back to work, Workers’ Compensation will send you tax-free temporary disability payments. However, if you are unable to return to work, you may be paid, on a regular basis, two-thirds of your average wages…or a lump sum. The amount is set by the state’s Workers’ Compensation agency, and varies from state to state and by industry.

In the event of death from a work-related injury or occupational illness, a death benefit is usually paid to the spouse or dependent children of the worker. Usually, the amount is two-thirds of the worker’s weekly salary and is paid weekly. In many states, the total amount paid is limited, while other states limit the length of time the benefit is paid.

Death benefits to spouses usually cease if the spouse remarries, although in some states a lump sum is then paid.

Death benefits to surviving children usually cease when the children reach adulthood unless they’re full-time students.

Burial expenses may also be paid.

Should A Lawsuit Be Filed?
Whether or not any claims for Workers’ Compensation are filed, injured workers — or the survivors of workers killed on the job — have the option of filing lawsuits for negligence against the party (e.g., manufacturer of a defective factory machine) they consider responsible for the injury or death.

Or they might sue their employer, accusing the company of failing to maintain a safe workplace, failing to carry the required amount of Workers’ Compensation coverage, or violating the laws of the Workers’ Compensation system.

If a lawsuit is contemplated, it is highly recommended that an experienced lawyer be hired to handle it. In many states, the services of a lawyer are required.

Documenting Your Case
It is important to keep a notebook or file of everything pertaining to your injury or illness. Document everything:

  • Location of the accident or injury?
  • The date and time.
  • Who witnessed the accident?
  • What exactly happened to you? (i.e. Did you slip and fall? If so, what caused you to slip? Did you hit anything else on your way to the ground?)
  • When and how did you inform your company or immediate supervisor? Etc.

Keep copies of every form you fill out and submit. Keep a diary of the doctors you see and the tests and treatments you get. Keep track of your symptoms and report to your doctor regularly. (Some states require you see your doctor every 45 days, for example.) Keep track of all expenses you incur, and check to see that they are paid.

You may be required to visit doctors within the insurance company’s network of providers. You should also have a doctor of your own choosing, even if you have to pay out-of-pocket, to evaluate your condition without being under the influence of the insurance company. You want someone who is looking to provide you with the best assessment and treatment for your needs.

If you are asked to get an Independent Medical Examination, be sure you keep the appointment. This is your employer’s insurance company’s way of confirming what your doctors and other medical professionals you’ve seen are saying about your injury or illness, and recovery process. The doctor performing the exam is working for the insurance company, and will not treat your or prescribe medication. He or she will be looking for reasons to minimize or disprove your disability claim, and stop paying your benefits.

Your doctors and medical facilities will submit invoices directly to the insurance company or your employer, and you will need to keep track of your receipts for travel expenses to and from doctor appointments and testing and treatment centers. You will submit these for payment yourself. Make note of when you sent the claims and when they were paid.

What to Do If Your Claim Is Contested or Denied
If your claim for Workers’ Compensation benefits is contested or denied, you should double-check your rights, review your claim with your doctor and an attorney, and then decide if you wish to appeal.

An attorney can help you choose one of the following courses of action:

Appeal—In most states, you can file an appeal if your claim is denied. It helps to have an attorney to guide you and strengthen your claim if it is not as strong as it could be. You may need to have additional statements from medical experts, safety engineers, witnesses or others to support your case.

Mediation—An independent, objective mediator, with expert knowledge of the Workers’ Compensation system, is chosen to help both sides communicate to resolve the problem.

Arbitration—If both sides agree on the issue but can’t come to an agreement on what to do, an independent arbitrator is selected to come up with a solution.

Other possible options include small claims court or a class action lawsuit.

If you sue — for medical costs, lost wages, etc. — in a small claims court, you may not need an attorney. In fact, in many such courts, attorneys are not allowed to represent clients. Each court sets a limit on how much a plaintiff can sue for.

If a number of current or former workers have all been injured by the same or similar conduct (or lack of it) by an employer or other party, they may get together with an attorney to file a class action lawsuit.

Due to the need for discovery (uncovering evidence, interviews, etc.) and the backlog of cases in most courts, either option may take many months or even years to complete.

How an Attorney with Workers’ Compensation Experience Can Help You
Your employer, their insurance company and their attorneys may have been involved in Workers’ Compensation cases for years. If you have never been involved in a Workers’ Compensation case, it would be unwise to go up against them alone.
You should have an experienced law firm on your side.

Your initial consultation, by phone, is free and without obligation. Its purpose is to help determine if you are eligible for Workers’ Compensation benefits and, if so, how the law firm can assist you.

On Workers’ Compensation cases, your law firm will be paid on a contingency basis, with the attorney receiving a specified percentage of the award if your case is successful, or no fee at all if it is not.

What to Do Right Now In Order To Claim Your Benefits
First-time claims are often denied because the claim form was not complete and/or did not properly or adequately describe the injury or illness or the cause of death.

If you need help in filling out a Workers’ Compensation claim form—if you’d like to ensure that it states your case in the strongest possible terms and includes all the information needed—an attorney with relevant experience can help you get your claim resolved in the shortest possible time.

If your claim for benefits is contested—if the insurance company sends it back on a technicality or refutes your doctor’s or witnesses’ statements—an experienced attorney can help you revise it and strengthen it.

Or if your claim is denied by the Workers’ Compensation agency, but you are certain that you are entitled to benefits, an attorney may be able to revise it, strengthen it and resubmit it on appeal.

With thousands or tens of thousands of dollars at stake, you may need all the help you can get…especially if that help costs you nothing (except for expenses) unless you win.

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