I often get questions from injured workers wanting me to give them an overview of how workers’ compensation works. In its most basic sense, workers’ compensation is when an employee gets hurt on the job and the employer’s insurance company pays for the injured workers’ medical bills and lost wages. Benefits may also be available if an employee sustains a permanent injury as a result of the work injury. In addition, workers’ compensation benefits include vocational assistance if an employee’s work injury is severe enough that the injured worker is precluded from performing their prior job duties. These vocational benefits may include assistance in finding suitable employment through job search or even additional training.
One of the most frequent phone calls I receive is an injured employee explaining to me that their employer was negligent when the employee got hurt and that they’ve experience “pain and suffering” related to the work injury. In the world of workers’ compensation, negligence is irrelevant and there isn’t compensation for “pain and suffering”. Workers’ compensation is an insurance type benefit and all employers are required by law to have work comp insurance coverage for their employees. Workers’ compensation is seen as a no-fault system meaning it doesn’t matter who was at fault when an employee gets hurt on the job so long the employee got hurt while performing his/her job duties. Work comp is also available to employees who receive a disease or illness as a result of their work duties. Injuries and illness that are compensable under workers’ compensation can occur suddenly, such as falling off a ladder and breaking a leg, or they can be brought on by repetitive actions such as machinist who develops carpal tunnel syndrome over time. Workers’ compensation is also available for injuries that occur while traveling for business, running a work-related errand, and in some cases injuries that occur at a business related social function.
The reason for workers’ compensation is a no-fault system as opposed to an at fault system is to make it easier for an employee to qualify for work comp benefits when they are injured. With the concept of fault thrown out of work comp, claims can be processed quicker which ultimately allows injured workers to receive wage replacement and medical care immediately following an injury. If work injuries required proving who was at fault, claims would be held up in the courts and an injured worker would be left without any pay or medical coverage while on the mend from a work injury. This was the tradeoff between the employers and employees; the injured worker gets benefits regardless of who was at fault and the employer gets protection from having to pay large sums of money for pain and suffering.
From a medical standpoint, when claims are accepted, it’s common for certain medical treatment to be denied at a later point. Most common reasons for denial from the workers’ compensation insurer are that the work injury did not bring about the need for the recommended treatment, or that the recommended treatment is not necessary. When this occurs, a medical hearing is scheduled and a workers’ compensation judge determines whether or not the recommended treatment should be approved. If it’s approved, the workers’ compensation insurer is responsible for paying for the treatment (and the corresponding missed time stemming from the treatment). If it’s denied, the employee is responsible for paying for the treatment (or the employee’s own personal insurance).
Lastly, rehabilitation benefits are also commonly disputed. In a typical accepted claim, an injured worker will be assigned a qualified rehab consultant (QRC) to oversee the employee’s return to work. Often times there is nothing more stressful than being out of a job that you’ve been doing for many years because the work injury has produced work restrictions that make you unable to perform that job. That’s why a QRC can be so helpful for people in those situations find suitable employment with the date of injury employer or some other employer. Work comp insurers common defenses for these issues is that the work injury isn’t the need for the work restrictions or that the employee has a suitable job within the work restrictions already. When this occurs, a rehab conference is scheduled to determine whether or not the employee is entitled to rehab benefits.
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