Workers Compensation Benefits

Accidents do happen. Sometimes, they are small, fluky, maybe wrong place at the wrong time. But if an employee slips on a puddle, breaks a leg or severs a finger — just to name a few workplace calamities — it should trigger the process of workers compensation benefits. And that’s a mammoth undertaking.

Workmans comp — as it’s commonly known — is a state-mandated program that covers expenses due to an employee’s work-related injury or illness. It’s available in all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands.

According to the latest statistics, the payments for workers comp benefits are rivaling the annual sales figures for the Walt Disney Company. In 2016, workers comp paid a total of $61.9-billion, including medical benefits of $31.2-billion and wage loss compensation of $30.7-billion.

Who Is Covered by Workers Compensation?

State laws require nearly all employers to carry workers comp insurance, which pays out costs ranging from an ambulance ride to the emergency room to physical therapy to lost wages to compensation for the remainder of an employee’s life.

In 2016, the most recent year when data is available, there were 138 million employees covered by workmans comp. That represents about 86.5% of all jobs in the workforce.

A study commissioned by the National Academy of Social Insurance determined that employees filed 2.9 million cases for workers compensation in 2016, about 900,000 of which resulted in employees missing days of work. Another 700,000 cases resulted in the employee transferring to another job or being restricted in the same job.

Experts advise you that if the accident was minor, you should be able to navigate the system by yourself, but if it was serious you would be better served to have a workers compensation attorney on your side.

“When I meet with a client, the first thing I do is explain how one-sided the system has become,’’ said attorney Leo Gomez, a workers comp specialist based in Tampa.

“You must explain how critical medical evidence is to the outcome of every case, and to also document the extent of the injury and provide corroborative evidence in support of the claim. You just have to be really well-informed. Because this system isn’t going to automatically work for you.’’

What Does Workers Comp Cover?

The specifics will differ from case to case and state to state, but in general workers compensation will cover medical care, lost wages, vocational rehabilitation and funeral costs in the event of a work-related death.

Medical Care

It includes immediate concerns such as emergency room visits, ambulance rides and other medical bills, along with surgery, rehabilitation and treatment from specialists. It also covers problems and illnesses that develop over a long period of time from doing the same injurious activity — not just incidental accidents — things like carpal tunnel syndrome or back problems from repetitious movement.

Medical bills will be paid as they are incurred. Doctors should directly bill your employer or the workers comp insurance company. If you’re covered for an industrial injury in your state, you should NOT be required to pay for the treatment. The amount of your medical bills does not impact the eligibility of your benefits for amount of time lost or loss of earning power.

Most states offer reimbursements for traveling to doctor appointments or treatment, including mileage, tolls and parking costs.

According to the Social Security Administration, approximately 75% of workers comp cases involve ONLY medical benefits.

Lost Wages

If you’re unable to work, the insurance company must pay for at least a portion of your missed wages during recovery.

For the most part, lost wages are compensated at a rate of two-thirds of your weekly wage, up to a state-mandated maximum. . For example, the state maximum in Florida is $878, while in Illinois it is $1,300.Those benefits are paid by the insurance company and are NOT taxed.

The amount of compensation you receive depends on the category of your workplace injury. A broken arm, for example, is not in the same category as a lost arm. Likewise, injuries may affect your ability to do your job in varying degrees.

The system is designed so that each injury will fall into one of four categories, depending on its severity, and its significance to your line of work. Lost wages are derived from one of the following categories:

Temporary Total Disability (TTD) — If you’re injured on the job and can’t return to work right away, you’re entitled to Temporary Total Disability benefits, which are generally paid weekly at the rate of two-thirds of your salary (sometimes subject to a maximum or minimum rate). Example: If you make $600 per week, you should receive a weekly check of $400 for the period of TTD. Many states have capped the maximum amount of TTD at $1,000 per week. Keep in mind the $400 check is tax-free.

Temporary Partial Disability (TPD) — If you return to work in a limited role after an on-the-job injury — but haven’t achieved Maximum Medical Improvement (MMI) and you’re earning less than your pre-injury weekly salary — you’re in line for Temporary Partial Disability benefits. It’s generally payable at two-thirds of the difference between your current earnings and what you were paid at the time of the injury. TPD is the rarest form of a workers comp benefit.

Permanent Total Disability (PTD) — If you can never return to gainful employment — meaning you are ruled permanently and totally disabled due to an on-the-job injury — you should receive Permanent Total Disability benefits. They are payable for life at typically two-thirds of your weekly salary. PTD makes up 11% of the total workmans comp claims.

Permanent Partial Disability (PPD) — If a physician has assigned you MMI status and ruled you’re capable of returning to gainful employment, but you still have some loss of function or other problems due to an on-the-job injury, you should receive Permanent Partial Disability benefits. It’s obviously less than total disability. Benefits are calculated differently by state and might depend on the body part that was injured.

Does Workers Comp Pay for Time Off for Doctor’s Appointments?

Yes. That time is considered “lost wages” and the insurance carrier will pay the employee. In general, employers are obligated to pay employees their regular wages if there’s medical attention received or doctor’s appointments at the time of injury. Employers are not supposed to have their employees wait until their shift is over to receive the treatment.

In addition, employees should not need to use unpaid time off, sick leave or vacation for follow-up appointments. Anytime away related to the injured should be logged and reported to the workers comp insurance carrier.

Vocational Rehabilitation

In most states, if you can’t return to your previous job because of injury, workers comp require retraining into a new line of work. Vocational rehabilitation is that retraining.

Sometimes, you or your employer might use a vocational expert if you haven’t returned to work or if you’ve returned at a lower wage. The expert can recommend jobs that you are capable of performing with medical restrictions, sometimes giving a rating that could be used to determine PPD benefits. A common example might be a worker who shifts from highly physical work to a more sedentary desk job.

Death Benefits

There are workers comp death benefits. If a work-related accident causes your death — and there is an important distinction if an on-the-job death occurs outside of normal work activity — workers comp can cover funds for funeral expenses and burial costs. How valuable is that? The median cost of a funeral is approximately $8,755 — and that doesn’t include the cemetery plot, sometimes an additional $2,000. There are financial limits in some states, which may not cover all the funeral expenses, particularly if it includes an elaborate mausoleum.

Some policies cover death benefits, such as support payments to your dependents. There are also funeral insurance policies. Some offer benefits that pay for the deceased’s outstanding medical bills and other debts. Some can be purchased by individuals — and the cause of death doesn’t need to be work-related.

It’s also useful to know what is NOT covered by workers comp insurance:

• Pain and suffering
• Safety improvements
• OSHA penalties
• Injuries to customers
• Wages for a replacement employee

When Does Workmans Comp Start Paying?

Most benefits start immediately for serious accidents and within 14 days if there is a question about how serious the injury will be.  In most states, the employers must pay your medical bills (related to the work-related injury) before the workers comp claim is formally accepted.

Once the claim is accepted, you’re eligible for all other workers comp benefits, depending on the severity of your injuries and ability to return to work. You should not miss a regular paycheck. The workers comp checks for lost wages should arrive on your normal pay period schedule.

How Long Does Workers Comp Last?

Length of the benefits varies by state. Temporary benefits are limited in the range of three to seven years. If a physician rules that your condition has stabilized and no major changes are expected (better known as MMI) , the TTD payments could be suspended.

There is generally no limit on permanent disability benefits, but some states terminate them when the employee reaches age 65.

Can You Work While On Workers Compensation?

You can, usually while on TPD. Your doctor might say you can return to work on a limited basis — maybe three hours a day or three days a week. In that case, you will usually receive two-thirds of your lost income, generally the difference between what you’re earning before the injury and what you’re earning now. Your employer, through the workers comp system, is required to do this when you shift to light-duty or part-time positions due to an injury.

Can You Get A New Job While On Workers Comp?

Yes, you can get a new job while on workmans comp, but be informed. Although workers comp benefits are not tied to continued employment, there are situations that should be envisioned.

First, if you receive a job offer while receiving workers comp benefits — and you’re not on leave due to the injury — it’s no different than anyone who is changing jobs. You give your notice, change jobs and start the new job. If your injury gets worse or you need additional treatment, your rights remain the same.

But be sure to discuss your medical condition with your medical care providers. Get their approval. Don’t accept a new job if you might later find that you can’t perform due to your injury. That could complicate your workers comp case.

If you accept a new job and are receiving TPD, contact the workers comp insurance company. Tell the adjuster about the new job, what it pays and when you start. Ask if more documentation is needed.

If your new job is another state, remember that every state’s workers comp system is different. It could be difficult to find a workers compensation doctor in a new state to accept payment through out-of-state workers comp insurance. It’s wise to find caregivers in the new state before relocation.

Before relocation to another state, you should make sure the workers comp insurance company has your contact information. Also get written authorization for new medical care providers and make sure they have your medical records.

Can You Sue Your Employer for A Work Injury?

If you feel there was a reckless or intentional action by your employer that caused your injury, yes, you can file a lawsuit. Be forewarned: That decision waives your right to workers comp benefits. But if your lawsuit is successful, you could receive damages for medical expenses, lost wages, pain and suffering, and mental anguish.

Employers are prohibited by law for retaliating against an employee for filing a workers comp claim. If you believe this occurred, the employer should be reported immediately to the local workers comp office.

“It’s very common for someone to hold off reporting an accident because they don’t want to jeopardize their position at the company,’’ said Gomez, the workers comp attorney. “It’s understandable, but sometimes they torpedo their claim from the beginning by waiting too long to report the accident.

“There are still about 80% of people whose claim or benefits are denied who do not seek any legal assistance. They get a call from the adjuster saying, ‘We can’t pay you anymore.’ And they go, ‘OK,’ and just figure that’s the end of it. They don’t have the knowledge or they are hesitant to push back because of (potential retaliation).’’

Research funded by the Bureau of Labor Statistics concluded there was “significant underreporting’’ for amputations under workers compensation systems in three states. The American Journal of Industrial Medicine theorized that phenomenon could be caused by “concerns about retaliation and stigmatization — enhanced by investigations regarding alleged fraud — (that) undoubtedly discourage workers from filing claims.’’