How Does Workers’ Comp Work? Understanding Workplace Injury Claims

Injured employees need to know how workers’ comp works. Here’s a good look at the workers’ compensation claim process.

Workers’ compensation insurance helps employees recover from work-related injuries and illnesses.

If an employee is hurt on the job, they often incur medical bills and may have to miss work while recovering from their injuries. Workers’ compensation benefits help cover these expenses.

While every state has its own laws, an injured worker can generally file a workers’ comp claim to seek payment for lost wages, medical costs, and more.

Filing this claim begins with a worker seeking medical treatment for their injuries and completing the requisite workers’ comp forms provided by their employer.

Once the injured workers’ claim is filed, it’s up to the workers’ comp insurance company to approve the claim or deny it. If denied, the injured worker has the right to appeal the decision. If approved, the worker is entitled to receive certain benefits from the insurer.

Depending on the cause and extent of your injuries, you may want to consult with an experienced workers’ compensation attorney for help filing your claim.

Are All Employees and Injuries Covered?

Most employees are covered through their employer’s workers’ comp insurance policy. Employees are normally entitled to workers’ comp benefits if they are full-time, working for a business with one or more employees, and suffer a work-related injury.

State laws often prohibit specific employees from receiving workers’ comp insurance benefits.

Ineligible workers include:

Circumstances that disqualify otherwise eligible workers: 

  • You suffered an injury while engaged in an activity against company policy
  • You suffered an injury because of drug or alcohol use
  • Your injuries occurred while commuting to or from work
  • Your injuries were deliberately self-inflicted

In general, Workers’ Comp covers injuries when working from home or working remotely.

Covered Workplace Injuries

Even if you’re a covered employee under your state’s workers’ comp laws, you still won’t qualify for benefits unless you suffered from a qualified workplace injury.

Most state laws say that employees will qualify for workers’ compensation benefits if they experience any injury or illness that occurred on the job. “On the job” means that you were injured or suffered an illness as a direct result of your employment.

Workers’ comp covers workplace injuries, as well as diseases or illnesses caused by hazardous workplace conditions, such as exposure to toxic chemicals.

Common injuries covered by workers’ compensation include:

  • Slip and falls at work
  • Back injuries from heavy lifting
  • Carpal tunnel from computer/keyboard work
  • Injuries suffered in a car accident

As to car accidents, workers’ comp will cover your injuries so long as you experienced them in the course of performing your work, regardless of your specific location.

Workers’ compensation is a no-fault insurance program, meaning a worker does not have to prove that an employer’s negligence caused or contributed to an injury. Workers only have to show that they were injured while on the job and performing work-related duties.

Read about how workers’ comp and unemployment benefits interact.

How to File a Workers’ Comp Claim

If you’re an eligible worker who is hurt on the job, one of your main goals is to receive compensation for your losses by filing a claim.

Get Medical Treatment and Notify Your Employer

The first step towards getting workers’ compensation benefits is for the injured worker to seek medical care and inform their employer about what took place.

If you aren’t treated at the injury site, visit an emergency room, your primary care physician, or an urgent care clinic as soon as practically possible.

Seek medical attention even if you don’t experience any immediate symptoms following your accident. Sometimes people get hurt on the job without any indication of an injury’s long-term effects.

Medical treatment will protect your health and help prevent your injuries from worsening. It will also help start the process of building evidence for your claim.

Ask for copies of your medical records from every healthcare provider you see. These records are important because they will help show the extent of your injuries throughout the life of your workers’ comp claim.

Once you receive medical care for your job-related accident, update your employer about what took place and the injuries you suffered.

Different business owners will have different systems in place for reporting on-the-job injuries.

For small businesses with a low number of employees, workers can usually just tell their boss what happened. In larger companies, injured workers may have to speak with a manager, foreman, or a member of the company’s human resources department.

If you’re uncertain about who you should talk to about your injuries, consult an employee handbook, the FAQ page on your company’s website, or your immediate supervisor.

It’s always a good idea to follow up on your incident report in writing. Email is fine. Make sure you keep a copy of this communication.

Complete the Required Forms and Start the Claims Process

Once your employer learns of your work injury, they should provide you with the necessary forms to officially begin your workers’ compensation claim.

The number and complexity of these forms will differ depending on:

  • The laws for the state in which the company is located
  • The type of injury/illness a worker suffered
  • The policies and rules of the employer’s insurance company

Most claim forms ask you to describe how and where you were injured, and the medical treatment you received. Your employer should tell you how to complete the forms and the person or department you should send them to.

The next step in the claims process is for your employer to file your forms with its insurance carrier, and depending on state laws, possibly your state’s workers’ compensation board. In some states, you can fill out the forms and file your claim online.

Once the claim is opened, the workers’ comp insurance provider will request medical records from your physician to verify the extent of your injuries.

Know Your Rights if You Get Hurt at Work

When filing your claim, know that state workers’ compensation laws protect several rights for eligible workers injured on the job, and they place specific responsibilities on employers after a work injury.

Injured employees have the right to:

  • File a workers’ comp claim without retaliation
  • Get prompt medical attention and treatment
  • Receive wage replacement benefits while unable to work
  • Return to work after you’ve recovered
  • Appeal a claim if it gets denied
  • Get assistance from a workers comp attorney with regards to the claim process

Most states say that an employer can legally fire an employee if they have to miss work because of their injury. For example, a business may fire you if your absence from work creates a hardship for the company.

Employers, however, can’t fire a worker in retaliation for reporting a workplace injury.

Some workers worry that a prior injury will affect a current workers’ comp claim. Provided you can show how the current injury clearly aggravated the pre-existing injury, you should receive compensation.

Workers’ Comp Claim Denial and Approval

After the insurance company receives your workers’ compensation paperwork, it will decide to approve or deny your claim.

When Claims are Denied

Insurance companies might deny an employee’s claim because of a finding that the injury was not work-related, the claim forms were not filled out correctly, or the claim was filed too late.

In any event, the insurer should send you a letter indicating the specific reason why your claim was denied. The letter should also describe the steps you can take to appeal their decision. You have the right to seek representation from a workers’ comp lawyer if you decide to appeal a claim denial.

If you have questions about a claim denial or the appeal process, you can visit your state’s workers’ compensation agency.

Approval and Benefits

If an insurance company finds that you’re a covered employee with a work-related injury, it will likely accept your claim. Once approved, employees are entitled to workers’ comp benefits.

Workers’ comp pays the injured worker’s medical expenses related to the workplace injury or illness. The employee can seek reimbursement for bills they already paid on their own.

Workers’ compensation coverage also pays a wage replacement benefit. Wage benefits usually fit into one of four categories.

Temporary Total Disability Benefits (TTD)

Employees may receive Temporary Total Disability (TTD) wage benefits if their work injury renders them temporarily unable to return to work.

Most states impose some type of waiting period (for example, 7 days) before a worker is entitled to receive these benefits.

Once the waiting period ends, an employee typically receives TTD benefits (with back pay for the waiting period) until they return to work, reach full recovery from their injury/illness, or state law says that the benefits should expire. Many state laws say that these benefits should end after a certain number of allotted weeks.

The specific amount of TTD benefits an employee can receive is determined by state workers’ compensation law. In most places you can expect about two-thirds of your average wages for the prior year.

Temporary Partial Disability Benefits (TPD)

State workers’ comp programs pay Temporary Partial Disability (TPD) benefits if the worker can return to work in a modified or light-duty capacity.

TPD wage benefits are usually the difference between your wages before your injury and your wages in the modified capacity, if you were placed in a lower paying job to comply with your medical restrictions.

TPD benefits end when you return to work in your original position, or state laws say that the benefits end because you’ve reached a certain number of allotted weeks.

Permanent Partial Disability Benefits (PPD)

Workers receive Permanent Partial Disability (PPD) benefits if they’ve suffered a workplace accident that results in a permanent impairment, but does not keep the worker from performing alternate employment.

The insurance company will expect the worker to make an effort to return to gainful employment. The partially disabled worker may be given vocational rehabilitation benefits if they require retraining for a new position because of their injury.

State laws differ in terms of the amount of a worker’s PPD benefits. Typically, though, the amount of a worker’s benefits increase with the severity of their injury.

Some states offer a lump sum based on the injured worker’s partial disability rating, as determined by the treating physician.

Permanent Total Disability Benefits (PTD)

Workers’ comp programs pay Permanent Total Disability (PTD) benefits to workers who can’t return to the workforce in any capacity because of their injury.

As with PPD benefits, the specific amount of permanent disability benefits often depend on state laws. PTD benefits may be paid over time, or in a lump-sum settlement. Many states reduce these benefits once you qualify for Social Security Disability Insurance.

Also, if a worker dies because of a workplace injury, their family may qualify for certain survivor benefits.

Who Provides a Worker’s Medical Care?

Once a claim is approved, many injured workers have questions about which doctor or other healthcare professional will provide their necessary medical care.

Many state laws let the insurance company call the shots as to what doctors an injured worker may see. In these states, you’d have little say in choosing your healthcare provider. But other states allow employees to pick the provider that will treat their injuries.

Workers’ Comp Settlements and Suing an Employer

Finalizing a workers’ compensation settlement can be tricky. Like any insurance company, workers’ comp insurers will pay out as little as they can get away with. Be ready to handle the tricks adjusters use to reduce workers’ comp settlements.

It’s important for an injured worker to know the full value of their claim and make sure the insurance company is handling it appropriately.

Let’s say an insurer determines that a worker is entitled to future medical expenses of $10,000 and temporary disability wage benefits of $3,000. The worker might accept the total of $13,000 in benefits and move on from their claim.

Or, the injured worker may take the position that their future medical expenses will be much more than $10,000. The worker can try to negotiate with the claims adjuster to recover more than $13,000 in compensation.

See how to handle a workers’ comp first settlement offer here.

In still other cases, an injured worker may decide to take their case before a workers’ comp judge and have them issue a ruling on the amount of benefits the insurer has to pay.

If a worker accepts an unfavorable settlement, most state laws prohibit the employee from filing a lawsuit against their employer. The inability to file a lawsuit means that you can’t recover for certain losses like pain and suffering or loss of enjoyment of life.

The only real exception to this general prohibition is if an employer intentionally hurts you or caused an injury while acting recklessly.

How a Workers’ Comp Attorney Can Help

If you’ve suffered a minor injury at work that requires limited medical treatment, you can likely handle your workers’ compensation claim on your own.

However, if you suffered a moderate to severe injury that requires significant time off work, you should contact a skilled workers’ comp lawyer for help with your claim.

Like with any type of insurance company, adjusters working for an employer’s insurer are trained to reduce and deny claim payouts. An adjuster is more concerned with their paycheck than yours.

Also, while you may have the best company or boss in the world, your employer has no say in the claim process. The employer’s insurance company determines your ultimate payout.

Experienced lawyers are better situated to negotiate with tricky claims adjusters. Attorneys will also have a better understanding of your state’s workers’ compensation system and will make sure you receive the correct amount in benefits.

If your claim gets denied, an attorney can also step in and help you appeal the denial. Most workers’ comp lawyers offer a free initial case evaluation, and their legal fees are only taken after they obtain a settlement on your behalf. There’s no cost or obligation to get your questions answered.

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Dustin Reichard, Esq. is an experienced attorney with 20 years of work in the legal field. He’s admitted to the Illinois State Bar and the Washington State Bar. Dustin has worked in the areas of medical malpractice, wrongful death, product liability, slip and falls, and general liability. Dustin began his legal career as a JAG... Read More >>