How Does Workers' Compensation Work?

Workers' comp insurance can be viewed as a perk of employment in many industries. Like any insurance, it prepares the policyholder to have the ability to pay for the unexpected. In this case, the policyholder is your employer, and the insurance payout should cover your medical expenses and lost wages if you become injured or develop an illness related to your work. It's a safety net for both the employee and the employer. In the event of serious injury or death, you can expect extended wage benefits. Some employees who can no longer perform their prior job duties can also use the vocational rehabilitation benefits to change to a career that can accommodate their disability. However, the specific benefits will depend on a variety of factors, such as the nature of the injury, the particular policy, and state or federal laws.

Generally, workers' comp insurance should cover all work-related injuries and illnesses, whether they happen suddenly or a chronic condition develops over time. However, not every aspect of workers' compensation law can be covered in this article as states have varying laws, some areas of the law are unsettled, and changes in systems can occur at any time. Because of this, if you have questions, we strongly suggest you talk to one of our qualified workers' compensation lawyers. Morgan and Morgan have offices across the country with local attorneys well-versed in your regional laws and federal regulations.

While every state in the union has some form of protection for injured workers, not every employer is required to carry workers' compensation insurance for all "employees" based on the worker's status. These exceptions may include workers in the following categories:

• Independent contractors
• Seasonal workers
• Farmers and farmhands
• Volunteers
• Railroad employees
• Companies that have less than a certain number of employees (the threshold is dedicated by state laws)

One category of employee is frequently problematic when it comes to labor disputes. Independent contractors are often miscategorized by employers. The miscategorization of an employee's status might be an honest mistake, or it may be done intentionally in an attempt to lessen the employer's responsibility toward them. In either scenario, with the proper legal representation, you can get reimbursed for lost wages and medical expenses if we can prove you're improperly categorized. If the employer is found to have purposely denied access to benefits and protections, there are further legal consequences for their actions. 

Some states make the process of filing a workers' compensation claim straightforward, while others have made it overly burdensome. Usually, your employer can direct you through the process. Here are general guidelines for making a workers' compensation claim.

Notify your employer of your injury - Alerting the employer of your injury or illness is a universal requirement in the claims process. Don't delay, as this can make your claim tougher to defend. Some states give you as little as three days. You'll need to fill out an incident report which should be as detailed as possible, including how you were injured and if there were any witnesses. If the injury causes an emergency, seek medical care immediately, then follow up with a notification and an incident report. Be sure to follow all requirements, stay in close touch with your employer, and keep copies of everything concerning the incident and treatment.

Follow requirements for medical care - Some states and specific companies have distinct requirements concerning medical treatment. You may have to use approved healthcare providers, so be sure to check with your employer before seeking care unless it's a medical emergency. You may have to pay upfront and get reimbursed later.

File a claim - You can begin the claims process after receiving treatment. Your employer should be able to direct you to the proper forms and information, or you can reach out to your local labor board or contact a workers' compensation lawyer. The claims process is strict and exact, and there are important deadlines to adhere to, so pay close attention and promptly respond to any emails or correspondence.

After the claim is processed, you should expect to be reimbursed for medical expenses and begin receiving wage benefits, typically two-thirds of your regular weekly wages. However, if you only miss a few days of work, wage benefits usually don't kick in. It varies by state, but injured workers typically do not recoup lost wages until they've missed seven or more days. If your injury or illness is serious, you may be entitled to temporary partial disability or permanent disability payments, which often require extensive paperwork and a vetting process to determine eligibility.  

Getting back to work - You may be entitled to take time off to recover from your work-related illness or injury, but you must comply with the healthcare provider's assessment of when you should be able to return to work and what type of work you can perform. If you disagree with the healthcare provider's review, you may be able to dispute it. However, the mandated process must be followed. Your employer has a duty to accommodate your disability, but there may be some exceptions depending on varying factors.

When you're injured while working within the scope of your employment, you should be eligible to receive workers' comp benefits. Still, the ultimate decision may be determined by specific factors. However, there are some incidents that will automatically result in a denial of access to benefits which include the following:

Injuries sustained during a commute to work - Unless some aspect of your employment expressly includes commute time as being "on the clock," an injury incurred during a commute to or from work would be excluded.

Injuries sustained while under the influence - Typically, if your injury occurred due to drugs or alcohol, you would be prohibited from getting workers' comp benefits.  

Horseplay - Roughhousing at the workplace doesn't usually benefit the employer, so an injury that occurs while fooling around on the job wouldn't be covered unless the employee's actions injured a third party.

Intentional injury - If an employee intentionally causes their own injury or illness, benefits are not included under workers' compensation insurance.

Illegal activities - If an employee is engaged in an unlawful activity and sustains an injury while at work, they will likely not be eligible to receive benefits.

Policy violations - Company policies, rules, and procedures are generally in place to protect workers and their employer's interests. Injuries that happen as a result of rule violations may not be covered under your employer's insurance.

Many injured employees may assume since the workers' compensation program is in place to protect workers' interests, they won't ever need the help of an attorney. In many cases, that may be true, but insurance companies are in business to make a profit. Paying out expensive and long-term claims cut into these profits, so you may find yourself in a dispute concerning what kind of medical treatments they'll pay for and how long you should receive wage replacement.

Your employer may also dispute whether your injury occurred while on the job or if it's work-related. This is particularly true if you have a pre-existing condition. Pre-existing injuries don't automatically mean you're prohibited from receiving workers' comp benefits, though. Some job duties may cause an existing injury to become aggravated or advance the degeneration of bodily function.

Another reason to hire a workers' compensation lawyer is if your long-term ongoing benefit eligibility is in question. Generally, if you've been on workers' comp for an extended period, you'll need to go in for an evaluation where they'll determine if your injury has improved or no longer exists. Morgan and Morgan can provide the legal advice you need to ensure you don't lose benefits unfairly.

To get started, contact us today for a free case evaluation to learn more about how workers’ compensation works.