Each state has its own workers' compensation system, a mandated insurance program to compensate employees who are injured in a workplace accident or rendered ill because of the job. There is also a workers' compensation program administered by the federal government for federal employees. In general, fault does not matter in a workers' compensation claim.
An employee may be able to bypass the workers’ compensation system and sue their employer if their employer’s actions were reckless or intentional.
Workers' compensation benefits are guaranteed whether the employee, the employer, a third party, or a coworker is at fault for an employee's injury. However, in exchange for the guarantee of benefits, an employee loses the right to sue his or her employer in civil court for personal injuries. The exception to this in most states is when your injury occurs because of your employer's recklessness or intentional misconduct. In such a situation, you may be able to sue in civil court and recover a full range of damages that are not available in the worker's compensation system, such as pain and suffering and punitive damages.
Workers' compensation benefits may be denied in some states when an injury is caused by an employee's drunkenness or drug use. Similarly, a self-inflicted workplace injury probably won't be covered. If a worker is committing a serious crime or violating company policy, he or she may not be able to recover benefits. Workers can also recover compensation for illnesses that are the result of work, such as stress-related digestive problems, or chronic injuries, such as carpal tunnel syndrome or other repetitive stress injuries.
Workers' compensation benefits include payment of hospital and medical bills, as well as loss of income during any period in which an employee is disabled. Disability benefits may be temporary or permanent. Usually, disability payments are about two-thirds of a worker's regular salary. In some cases, rehabilitation and retraining are also paid for through the workers' compensation system.
The Process for Obtaining Worker's Compensation Benefits
In most states, you must notify an employer within 30-45 days of an injury or illness, and a failure to notify may result in a denial of benefits. However, in some states, the notification period is shorter, and it is wise to immediately notify your employer so that the workers' compensation carrier can be notified and a report can be sent to the board that administers your state's workers' compensation system. You should give notification to to the person who manages you and HR.
Once the workers' compensation carrier knows of the injury or illness, it can start paying your medical bills and a percentage of your average weekly income. Alternatively, a workers' compensation carrier may reject your claim, in which case you may need to appeal the rejection with your state workers' compensation board. These appeals are usually more successful with the help of an experienced workers' compensation attorney. If your appeal fails, you may be able to ask the court to review the administrative judge's decision.
Once you know you are injured or ill as a result of workplace injuries, you should also obtain immediate medical care so that medical records can be used as evidence of your injuries in the event of a benefits denial. However, your employer or its insurer may refer you to a doctor of its choosing for what is called an Independent Medical Examination (IME).
Independent Medical Exam: required by the employer or insurer, often favors their interests
Impartial Medical Exam: potentially required by the state workers’ compensation agency, designed to be neutral
Insurers often select a doctor that they know will deliver a report that minimizes the seriousness of your injury or illness. The doctor who is chosen by the insurer may seek to identify your injury as a preexisting condition. You will be asked in detail about your medical history and the circumstances of the injury. In general, you should be honest and cooperative, but keep your responses to the doctor's questions brief and to the point, rather than trying to be exhaustive about any minor issues you have previously suffered that relate to the same body area as your work injury.
In some states, a separate impartial medical examination will be required by the workers' compensation agency. The doctor who administers this impartial medical examination will be chosen from a list of doctors whom the state believes are impartial and do not accept IME requests from insurers. Often, state law requires the administrative judge who hears your case to accept the opinions of the impartial doctor as binding evidence.