Part 3: Important Workers Compensation Information…
Most states today require employers to carry workers compensation benefits for their employees. Each state has its own specific rules to follow when filing a workers comp claim.
The frequently asked questions on this page will give you a good overview of how these claims work. Although your individual injury may be different, the following questions and answers will help you understand the process of a workers compensation claim.
We’ll use a scenario to demonstrate how workers compensation benefits work…
Justin has been working the day shift at a large national discount tire store for the past three years. His job is to dismount tires from customers’ vehicles and then repair or replace them with new ones.
Monday started off just like any other day. It was almost 11:00am and he’d already replaced 2 full sets of tires. He was using the Tire Stripper – a machine used to remove a tire from its wheel. Over the last 3 years he’d probably stripped over 1000 tires without incident, although today would be different.
As Justin began using the tool to pry the tires off the wheels it snapped in half sending one half toward the ground and the other half into his face and specifically, his left eye. He fell to the ground in agony while his coworkers helped him and called 911.
Justin was raced by ambulance to the nearest hospital’s emergency room. Because of the searing pain and constant flow of blood from the area around his left eye, he was triaged and brought to the front of the line. The emergency room physician took quick action to stem the bleeding. Once accomplished she sent Justin to the radiology department for x-rays of his skull, and particularly his left eye socket.
The doctor found lacerations and contusions to his face requiring 30 stitches, and a fracture of his left eye socket. The prognosis stated that with proper rest and medication he should be able to return to work in a couple of months.
While in the hospital Justin’s wife Suzanne drove to his workplace to pick up his personal effects. While there she spoke with Justin’s supervisor about his workers compensation benefits. A week later, with a large patch over his left eye, Justin was driven by friends to his job where he picked up some of his personal items.
Although feeling somewhat groggy and certainly in some discomfort Justin summoned the energy to speak with his supervisor to report the injury.
We take it from there…
Frequently Asked Questions about Filing for Workers Compensation Benefits:
Suzanne: I know I’m supposed to report an injury on the job. Are there any forms I need to complete?
Supervisor: Yes. Fill out this WC-33i form and return it within 10 days.
Suzanne: What should I do when we receive Justin’s ambulance and emergency room bills?
Supervisor: Bring them to our workers comp representative here and they will be taken care of.
Justin: I’ve been told I will have to see a plastic surgeon for what may be developing scars and another reconstructive surgeon to repair my fractured eye socket. Can I choose my own doctors?
Supervisor: Not really, unless they appear on the list provided to us from our workers compensation insurance company.
Justin: What does that mean?
Supervisor: You must choose a doctor from the list provided by our workers comp insurer, or else your treatment may not be covered. Here is a list of all of the approved doctors. You may see any of these.
Justin: What happens if I see one of the doctors and I don’t like her? Can I change doctors?
Supervisor: Yes, we have several plastic surgeons to choose from, as well as other physicians you may need. Here is a list of those physicians. If you go outside the list you may not be reimbursed for those costs.
Justin: Will I have to pay any deductibles or co-pay amounts?
Supervisor: No. As long as you stay within our approved list of physicians you won’t have any extra medical costs.
Justin: How about all my medications?
Supervisor: All your medications will be paid for if you choose one of the pharmacies on our list. Here is a list of those pharmacies.
Justin: How about all my out-of-pocket expenses… all the hospital parking lot fees every time I go see my doctors, or the bandages and salves for my skin? With gasoline at over $4.00 dollars a gallon we’ve been spending a lot on gas driving to pharmacies and doctors’ offices. Are these costs covered by my workers compensation benefits?
Supervisor: Those amounts will be covered as well. Keep a log of your medically-related expenses, and approximate the amount of gasoline also.
Justin: It looks like I may have to stay home and recover for several months. Will I lose my job?
Supervisor: No. If you will be physically able to do your job after you recover you may return to it at the same pay or, if there was a salary increase, the increased salary.
Justin: How about my lost wages? Will I still be paid while I am recovering?
Supervisor: You will be paid 2/3rds of your normal salary, but because that amount is not taxable your net salary should be about the same.
Justin: What if the doctors say I’m ready to return from work and I don’t think I am. What happens then?
Supervisor: Well again, you are welcome to get a second and even 3rd opinion from other physicians on our approved list.
Justin: Can I be reimbursed for pain and suffering? How about mental anguish?
Supervisor: No. Unfortunately the Federal Workers Compensation Act does not provide reimbursement for mental anguish or pain and suffering.
Justin: Will I be negotiating a settlement for my injuries with you?
Supervisor: No. A workers compensation insurance claims adjuster will be contacting you. You will be discussing and negotiating your claim with her.
Justin: What if I am not happy with the amount she offers over and above my doctors’ bills and out of pocket expenses?
Supervisor: You can file for an Administrative Hearing before a Judge or, if mutually agreed, before an arbitrator.
Justin: What does that mean?
Supervisor: It means the amount the claims adjuster has already offered will be withdrawn and you will start all over in a hearing before the Judge or Arbitrator. If at the end of the hearing you are awarded less money than the adjuster offered you will be out of luck.
Justin: So I will be forced to accept that amount?
Supervisor: Your only recourse will be to file an appeal. That can take time and some expertise if you want to have a chance at success.
Justin: Why do I have to go through the workmans compensation insurance? They don’t even pay mental anguish or pain and suffering?
Supervisor: Because the law says so. When workmans compensation law is in effect in your state and with your employer, you are bound by that law.
Justin: Is there ever a time when I could sue for more than my workers compensation benefits?
Supervisor: Rarely. But in the event the tool you were using was defective, or your employer should have known the tool might have broken as it had several times before, then you might be able to go outside of the workmans comp system. Quite honestly if you are considering that you really should seek the advice of a competent attorney .
Justin: What if I agree to settle my case and a year or so later my injury worsens. Can I reopen my case and attempt to receive more money?
Supervisor: No. Once you settle your case or have exhausted the appellate process, for all intents and purposes your claim is over.
Although it’s always possible to represent yourself in almost any case, doing so can have its drawbacks. With workers compensation laws and regulations changing frequently it is always a good idea to consult with a qualified workmans compensation attorney.
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