Workers’ Compensation and the Law

What Is Workers’ Compensation? What Are the Eligibility Requirements? What Benefits Are Available?

If you have been hurt while at work, you’re not alone. Studies by the National Safety Council indicate that almost 100,000 American workers suffer some type of job-related injury every week! That’s more than 7 million workplace accidents each year. Fortunately, almost all states have workers’ compensation. (Texas stands alone in allowing employers to opt out of its state workers’ compensation program.)

What Is Workers’ Compensation?

Federal law provides workers’ compensation benefits to federal workers, but most U.S. workers are covered by state workers’ compensation programs. Workers’ compensation programs are “no-fault” laws, eliminating any need for an injured worker to prove that their employer was negligent or otherwise at fault. Instead, to qualify for workers’ compensation benefits, a worker must prove only two things:

• That they were injured (or contracted an illness); and
• That the injury occurred (or illness was contracted) while the worker was in the course of their employment.

Though the law may vary in minor details from state to state, the rules governing workers’ compensation claims are generally as follows:

• Workers are entitled to temporary compensation if unable to work because of a job-related injury or illness. Typically, a person is not entitled to workers’ compensation until they have been unable to work for at least seven days.
• Workers are entitled to temporary compensation until they return to work or are deemed to have reached “maximum medical improvement.”
• Workers may be entitled to total permanent disability benefits if the injuries suffered make it impossible for them to return to work.
• Workers may be entitled to partial permanent disability benefits for certain types of permanent injuries, even if they are able to return to work.

Workers are not entitled to workers’ compensation benefits for injuries that are self-inflicted or that occur while a worker is engaged in an illegal act.

The Workers’ Compensation Process—How Do You File a Claim?

After a work-related injury, the worker must notify their employer of the injury as soon as possible, typically within 30 days. When notified, the employer will provide the injured worker with the necessary forms to submit a claim for workers’ compensation benefits. In most instances, the employer initially submits the claim to the workers’ compensation insurance provider and notifies the state’s workers’ compensation board. The employer may also request that the worker be examined by a doctor chosen by the employer. That does not, however, prohibit the injured worker from seeking medical care from their own physician.

Typically, when the workers’ compensation insurance company is notified of a claim, it sends investigators out to gather evidence relating to the claim. Based on its findings, the insurer makes the initial decision to accept or reject the petition for benefits.

If the claim is approved, the workers’ compensation insurance provider notifies the employer, who then notifies the employee. The insurance carrier and/or the employer may agree to pay periodic benefits or negotiate payment of a lump-sum settlement.

If the claim is denied, the worker must then turn to the appeals process set forth under state law. Typically, that process starts with a request to the workers’ compensation insurance company to reconsider the claim. Further appeals to a workers’ compensation board or commission may also be available in your state. You should consult a workers’ compensation attorney to determine whether you have grounds to appeal a denial of workers’ compensation benefits.

The Different Types of Loss Covered by Workers’ Compensation

Workers’ compensation provides for payment of benefits for physical injuries, as well as mental illnesses and injury, including depression and anxiety that prevent a person from working.

Injuries for which compensation is generally available include:

• Serious and catastrophic loss, such as broken bones, amputation or loss of limb, paralysis, traumatic brain or spinal cord injury, burns, and permanent scarring or disfigurement
• Repetitive stress or motion injuries, such as carpal tunnel syndrome, nerve damage, ligament, tendon, and muscle injury
• Joint and connective tissue injury, from foot, ankle, leg, and hip trauma to hand, arm, and shoulder injury
• Communicable diseases, such as COVID-19
• Occupational disease, such as mesothelioma, silicosis, cancer, and heart disease
• Mental health issues, including depression, stress, and anxiety

What Benefits Are Paid in a Workers’ Compensation Claim?

There are four types of compensation available through workers’ compensation:

• Compensation for lost wages—Compensation for lost income may be temporary or permanent, and it may be partial or total. As a general rule, an injured worker who is totally disabled is entitled to payment of 70% of their average weekly wage for the past 52 weeks prior to injury, subject however to a cap provided by state law. In the event of partial disability, the severity of the injury is determined, and the injured worker is entitled to a proportional percentage of the total disability benefits available.
• Reasonable and necessary medical expenses—This includes costs for medical care associated with your injury, from doctor and hospital bills to the costs of medication, medical devices, rehab, and physical therapy. Typically, there are no specific dollar amount limits in workers’ compensation laws, and workers’ compensation covers deductibles and copays.
• Vocational rehabilitation—If your injury or illness prevents you from returning to your prior position, you may be entitled to compensation to pay for programs to help you return to gainful employment, such as job training, career counseling, and job placement services.
• Death benefits—Surviving family members of a worker killed on the job have a right to benefits. Most states require payment of a minimum amount for the costs of burial. Some states require a fixed death benefit, while others grant a weekly payment of benefits to a spouse and/or surviving children, typically until the death or remarriage of the spouse or until a dependent child reaches a certain age (usually between 18 and 22).

How Do Employers Pay for Workers’ Compensation Benefits?

An employer covers the potential costs of a workers’ compensation claim in one of two ways—through either a workers’ compensation insurance policy or self-insurance. Self-insurance means that the employer pays the benefits directly from profits and revenues of the company. Most states require that an employer purchase workers’ compensation insurance or submit to a rigorous qualification process to be self-insured.

Are All Employers Required to Provide Workers’ Compensation Benefits?

Though the laws vary somewhat from state to state, every jurisdiction (except Texas) requires most employers to provide workers’ compensation benefits to injured workers. In some states, employers are not required to provide workers’ compensation insurance unless they have a certain number of employees. For example, in Mississippi, workers’ comp is not mandatory for employers with less than five employees.

In Texas, employers may opt out of the workers’ compensation program; however, an employer who opts out can then be sued civilly for any work-related injuries. In all other states, workers compensation is considered the exclusive remedy for recovery of losses caused by a work-related injury.

Certain types of jobs are generally not covered by workers’ compensation, including domestic employees, some farm laborers, casual or seasonal employees, independent contractors, volunteer workers, real estate agents, and members of the clergy.

Is COVID Covered by Workers’ Compensation?

COVID-19 is generally considered to be covered by state workers’ compensation programs, provided the virus is contracted on the job. Many states have enacted new laws in the wake of the pandemic, holding that workers in certain front-line occupations are presumed to have contracted the disease while working. Accordingly, an employer who seeks to challenge a workers’ compensation claim for a healthcare worker or first responder must prove that the infection was not work-related.