Frequently Asked Workers’ Compensation Questions and Answers

Get fast answers to the most frequently asked workers’ comp questions. You’ll be on your way to getting the compensation you deserve for your workplace injuries.

Workers Compensation is a state-regulated system of insurance to help injured workers by paying for their injury-related medical treatment and replacing part of the worker’s lost wages.

We’ve answered the most commonly asked questions about workers’ compensation eligibility, benefits, and problems.

Workers Compensation Eligibility

Who can get workers’ comp?

Every state and territory in the United States requires employers to provide workers compensation insurance to their employees within certain limits. Very small companies with few employees may not be obligated to purchase workers compensation insurance.

Federal workers are covered under a separate worker’s compensation program.

Some workers may not be eligible for workers compensation, for example:

  • Independent contractors
  • Seasonal workers
  • Domestic workers like babysitters or housekeepers
  • Undocumented workers

Each state has its own rules, eligibility requirements, and limitations.

What if the work injury was my fault?

Most workers can get workers’ comp benefits even when their injury was caused by their own mistake or negligence on the job.

Eligible workers are entitled to workers compensation benefits regardless of fault, with some exceptions.

Workers who are injured in the commission of a crime, while under the influence of alcohol or drugs, or who intentionally injured themselves may legitimately be denied workers compensation benefits.

Is there a deadline for filing workers’ comp?

There is always a deadline for reporting injuries and filing a workers’ compensation claim. Deadlines are different for each state.

Find your local State Workers’ Compensation Office contact list for more information about your state’s rules and deadlines.

Filing a claim is not the same as notifying your employer. You’ll need to do both.

If you’re injured on the job, get immediate medical attention. Then, promptly notify your employer of your injury.

Once notified, your employer should give you the forms and instructions for filing your actual workers’ compensation claim. If you have not received the information from your employer, don’t wait.

Contact your local Worker’s Compensation office to file your claim. If you miss your state’s deadline for filing your claim, you may forfeit your eligibility for medical benefits and wage replacement.

What if I was hurt during my lunch break?

Workers who are injured off-the-clock, during a lunch break, or commuting to and from work are generally not eligible for workers’ compensation benefits.

However, if you are acting on the behalf or at the request of your employer, you will likely have a legitimate workers’ comp claim even if you are injured outside your normal workday.

For example, if you get hurt running out to pick up lunch for you and a couple of your friends you won’t be covered. However, if you were hurt while heading to the deli to pick up lunch for a client meeting at the request of your supervisor, you’ll have a legitimate claim.

What if I have a pre-existing condition?

You can make a claim for workers’ compensation for any injury that occurs on the job, even when your injury is a repeat or an aggravation of an old injury or pre-existing condition.

Never try to hide or lie about a prior condition. It’s very important when reporting your injury and talking to your medical provider that you are careful to distinguish your new symptoms and new injury from your older condition or injury.

Don’t make excuses for your symptoms and do be specific.

For example, instead of saying, “My old back is killing me from moving those boxes this morning!”

Be more specific and say, “I was moving boxes of copier paper first thing this morning. When I picked up the third box, I felt something pop in my back. My back immediately hurt so badly that I couldn’t straighten up and felt sick to my stomach. I had never felt that kind of pain before I picked up that box.”

Payments and Benefits for Workers

What can I get from workers’ compensation?

Workers’ compensation will cover the cost of your medical treatment, physical therapy, rehabilitation for serious injuries, out-of-pocket expenses (for medical equipment and travel to injury-related appointments), and a portion of your lost wages.

Wage replacement benefits in most states are about two-thirds of your base pay, up to your state’s maximum weekly benefit limit. State limits range from $390 to over $1,200 per week for wage replacement benefits.

How is wage replacement calculated?

Wage replacement benefits are typically calculated as an average of your weekly pay for the prior 52 workweeks. Don’t trust the workers’ comp insurance company to accurately calculate your wage benefit.

Insurance companies are notorious for making mistakes in calculating wage benefits, and those errors are never to the benefit of the worker. You have a right to ask the workers’ comp representative to provide you with copies of the wage records they used to arrive at your benefit payment.

If the insurance company won’t cooperate or refuses to correct an error in your wage benefit calculation, contact an experienced workers’ compensation attorney to discuss your case.

What if I’m disabled?

Many workers are injured badly enough that they can never return to the type of work they were doing before they were hurt, or they are unable to work at any job after their injury. Permanently injured workers are generally offered disability settlements in addition to their regular wage replacement benefit.

Disability settlements can be a lump sum or payments over time. The settlement amount depends on the injured worker’s category of disability.

Definition of Workers’ Comp Disability Categories

  • Temporary Total Disability completely prevents you from working for a limited amount of time.
  • Temporary Partial Disability prevents you from doing some, but not all of your job duties for a limited amount of time.
  • Permanent Total Disability prevents you from ever returning to work, whether for your current employer or another employer.
  • Permanent Partial Disability is a permanent injury that partially impairs your ability to work.

Workers’ Comp Medical Issues

Can I use my own doctor?

Most workers’ comp plans require injured workers to be evaluated and treated by medical providers from the insurance company’s pre-approved list.

Check your state’s rules. Many states will allow you to change over to your personal doctor after a certain period of time.

You can always seek a second opinion from a doctor of your choosing, but you may have to pay out-of-pocket and not be reimbursed by workers’ comp. It may be worth the cost to pay for a second opinion if you disagree with the treating physician’s opinion of your ability to return to work.

Workers’ compensation should reimburse the cost of necessary emergency care at the time of your injury, regardless of the medical provider.

What is an independent medical exam?

The insurance company has the right to send you to one of their hand-picked doctors for an Independent Medical Exam (IME) at any stage of the workers’ comp claim process.

You’ll be asked to undergo an IME when:

  • Your doctor requests expensive tests or treatment the insurance company doesn’t want to approve
  • The insurance company wants to prove you’re faking your injury or malingering
  • You’ve reached maximum medical improvement, and they need to determine your level of disability
  • The insurance company wants to push you into a quick settlement so they can close your claim

The IME doctor will not treat your injury or help you in any way. The IME doctor is only there to gather information for the insurance company to use against you. Refusing an IME gives the insurance company a fast excuse for terminating your worker’s compensation claim.

Do I have to go back to work before I’m ready?

Your treating physician may release you to return to work with or without restrictions. Restrictions can be anything from seated-only work, to limited hours of work each day, or limitations on standing or lifting.

When your doctor releases you to return to work and your employer has a job for you to do that will meet your restrictions, you must report for work as assigned. Failing to return to work can result in termination of all your workers’ comp benefits.

If the insurance company and their doctor are pushing you back to work before you’re ready, contact a workers’ compensation attorney right away.

Fighting for Your Compensation

What if my claim is denied?

If your initial workers’ compensation claim has been denied, don’t give up. You have the right to file an appeal to dispute the claim denial.

Carefully read through your denial letter. The letter from the workers’ compensation insurance company should clearly state the reasons why your claim has been denied. You’ll need to respond to each of those reasons in your appeal.

Make sure you understand any deadlines that you’re facing. The letter should tell you where to send your appeal and what the deadline is for sending in your paperwork.

Can I sue my employer?

Workers comp is designed to protect employees by providing medical and wage replacement benefits without the employee having to prove the employer was negligent. The flipside of that is the employer is protected from lawsuits by injured workers in most cases.

You can sue your employer for your injuries if your employer did not carry the required workers’ compensation insurance.

If you’re hurt because your employer went berserk and physically attacked you, you can probably file suit for your damages. Otherwise, you can’t sue your employer outside of workers’ compensation unless your injuries are the result of malicious or exceptional negligence by your employer.

What’s a third-party lawsuit?

When it comes to workplace injuries, a third-party is any person or business other than your employer who contributed to the circumstances that caused your injuries.

Some examples of third parties that may have contributed to workplace injuries are:

  • Manufacturers of defective machinery or tools
  • The at-fault driver if you were injured in a vehicle accident while working
  • Subcontractors or vendors at a worksite who were negligent
  • Property owners other than your employer responsible for unsafe conditions

Workers’ compensation benefits are limited to actual medical costs and a portion of your lost wages.

If you and your attorney file a lawsuit against a negligent third-party for your injuries, you can seek recovery for all your expenses including replacement services, pain and suffering, consortium claims by your spouse, full wage loss, future lost earnings, and in some cases punitive damages.

Who can help me with my claim?

You don’t have to face the insurance company and their army of experts by yourself. Their only interest is in protecting the company’s bottom line – not your financial future.

You’re entitled to full compensation for your workplace injury through workers’ compensation and from other parties who may be responsible for your damages.

If you’ve been severely injured on the job, there’s too much at stake for you to leave it all in the hands of the insurance company.

It costs nothing to find out what a good personal injury attorney can do for you.

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Charles R. Gueli, Esq. is a personal injury attorney with over 20 years of legal experience. He’s admitted to the NY State Bar, and been named a Super Lawyer for the NY Metro area, an exclusive honor awarded to the top five percent of attorneys. Charles has worked extensively in the areas of auto accidents,... Read More >>