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Workers' Compensation Process

Workers' compensation is a type of insurance that helps employees to seek compensation in the event they’re unable to work totally or partially. Workers' compensation also helps to protect employers and affords them the ability to pay their employees in case there is an injury. If a person has been injured at work, they can generally expect the process for filing a claim to go as follows.

Seeking Medical Treatment

Employees need to get medical treatment immediately. If it is an emergency, the employee can go to a hospital’s emergency room. It’s important to discover the nature of injuries and the best treatment as quickly as possible. Even if the employee doesn't feel as though they've been injured or is not in pain, they should still seek treatment as injuries may not become noticeable until later. If an employee waits too long to seek medical treatment after the injury, it may be argued that the injury was due to other factors, and it may impede the workers’ compensation process or approval.

According to some workman’s comp policies, it may be required to see a certain doctor. However, it is generally possible to seek a second opinion from another doctor. Failure to seek medical treatment altogether, however, may cause the workers' comp claim to be denied.

Employer Notification

Employees should notify their employers, in writing, of any incidents as quickly as possible; however, the time period to inform employers of an injury can be anywhere between 30 and 45 days. Some states, like New York, Texas and California, require that employees notify their employers within 30 days. Failure to notify an employer can result in the inability to file a claim. Even if an employee notifies their employer informally, it is best to follow up with a form detailing the date and the location where the injury occurred.

Official Claim Form

Once an employee seeks medical treatment, a medical report and other information regarding the injury and general health will be recorded. A medical report is sufficient for the purposes of a claim. Employers usually provide the official workman’s comp claim form, but if not, it can be obtained from the state board of workers’ compensation. The workers’ compensation form should include:

  • The time, date and location of the injury
  • The names of people who were involved in the incident
  • How the incident happened
  • Whether or not the employee sought any medical treatment for the incident

After the workers’ compensation form has been completed, the employer files the employee’s claim with the insurer and the state board of workers’ compensation. After the claim is evaluated, an administrator will notify the employee as to whether or not their claim was approved and how much they might be entitled to.

Benefits

Employees with approved claims may be entitled to different types of workers' comp benefits, such as lost wages, medical bills and vocational rehabilitation. However, employees cannot seek benefits for pain and suffering. The duration of benefits varies according to state. However, a general time frame of these benefits is between three and five years. It is important to note that benefits may cease when an employee reaches the age of 65.

The amount that workers' comp benefits usually cover is generally around 60 percent of the employee’s average weekly pay. However, an employee that has a partial disability may expect a different amount. This is determined, first, by the employee’s current earning capacity.

Disability benefits can be classified as either partial or total and permanent or temporary. A temporary disability is as the name implies. It is expected that an employee will recover from a temporary disability. A permanent disability is not expected to get better. A treating doctor may refer to permanent disability as a “maximum medical improvement,” as the employee has plateaued in recovery, and further treatment would not prove beneficial.

Total disability means that an employee cannot seek any type of work. Partial disability means that an employee has some capacity to work, but it may be limited to certain tasks. For instance, the employee may not be able to lift more than 10 pounds or may be required to sit to perform work duties.

Appealing a Denial

If an employee's claim for workers' compensation benefits is denied, they may choose to appeal the claim. Depending on the state, there may be a limit to how long the employee has to file an appeal; this will be detailed in the denial letter. In California, for example, employees have 20 days in which to file an appeal. To appeal a case, an employee needs to know the reason they were denied, and there are different reasons this could have occurred. Some examples of reasons why claims can be denied include:

  • The claim or injury was not reported in time.
  • The employer disputes the claim.
  • The injury cannot be compensated or does not necessarily require medical treatment, such as in the case of stress-related injuries.
  • Medical treatment was not sought in the allowed time frame.
  • There was insufficient evidence to support that the injury was caused by work.
  • Paperwork is filed improperly.

Appeals will first go through the local state workers' compensation board. If the denial is upheld, then the claim may be taken to higher levels, depending on the statutes in that state. Appeals can often be complicated and difficult to navigate. A workers' comp lawyer can often help make the process easier by gathering and presenting documentation and further evidence.

Speak to an Experienced Workers' Compensation Attorney Today

This article is intended to be helpful and informative. But even common legal matters can become complex and stressful. A qualified workers' compensation lawyer can address your particular legal needs, explain the law, and represent you in court. Take the first step now and contact a local workers' compensation attorney to discuss your specific legal situation.

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