What Is Workers’ Compensation?
In America, we have a system in place that is designed to financially support employees that are injured while they are working or on a job site. This program is known as workers’ compensation and is a major benefit to those that do sustain such an injury. Under the regulations of this program, any time that an employee is injured while on the job, he or she is eligible to receive funding from the employer or, more commonly, the employer’s insurance company.
Workers’ compensation is a right, not a privilege and any and all employees are eligible to receive it. Typically, the funding is meant to cover all medical expenses that stem from the injury, including but not limited to doctors’ visits, hospital stays, medication, and ongoing physical therapy. Under certain circumstances in which an injured employee is rendered unable to work due to the workplace injury, financial compensation for lost wages can be given out as well. This is usually around 60% of the employee’s normal salary.
In this guide, we will highlight the responsibilities that both employers and employees have in the process of obtaining workers’ compensation, what factors go into funding calculations, various scenarios that may impact benefits, and what you can do if your claim is initially declined.
Workers’ Compensation Employer Responsibilities
As noted earlier, workers’ compensation is a right and therefore it is legally required for a company to offer it to their employees in the event of an incident. In Florida, it is also legally required for a company of more than four employees to carry workers’ compensation insurance, which will allow for the dispensing of funds from the insurance company in the event of an incident. Employers in Florida must also do their due diligence in making employees aware of this program, including posting signs indicating compliance in obvious places in the workplace.
In the event that a workplace injury does occur, it is the responsibility of the employer to file an incident report, after providing any emergency medical treatment of course. This report should be filed to the region’s workers compensation board office and insurance company. Additionally, the employer must not retaliate against workers that are injured on the job. This means that they cannot fire the individual or otherwise punish them for being injured. Failure to comply with this and the other noted responsibilities can result in fines, lawsuits, and criminal prosecutions against the employing company.
Workers’ Compensation Employee Responsibilities
Of course, employees also have responsibility to uphold when it comes to workers’ compensation. Firstly, every employee should work responsibility and try to avoid injuries if possible by adhering to all safety protocols and policies. Failure to do so, may jeopardize a workers’ compensation claim, so this is important and also applies to any actions taken after an incident.
If an accident does occur though and a workplace injury is sustained, it is up to the employee to report it and file an incident report with the company’s human resources department, after seeking emergency medical attention, of course. Doing this will not only speed up the process, but alert the employer and insurance company that compensation needs to be dispensed. Additionally, it is up to the employee to maintain accurate and detailed records of all medical treatment related to the workplace injury. Compensation can only be dispensed if the company knows what it is paying for, so keeping excellent records of all treatments will go a long way to ensuring that the maximum amount of benefits are given out. Obviously, necessary paperwork and forms should be stayed on top of by the employee as well, as this too will speed up the process of dispensing compensation funds.
What Types of Incidents Are Not Covered by Workers’ Compensation?
The vast majority of workplace injuries do make an individual eligible to receive workers’ compensation. That being said, there are certain circumstances and kinds of injuries that may invalidate a workers’ compensation claim.
The most common circumstance occurs if the injured employee was under the influence of drugs or alcohol at the time of the incident. That is why drug tests are sometimes given out following the incident report being filed for a workers’ compensation claim. If this is the case, no workers’ compensation can be dispensed because the injury could have been caused by this influence and not a careless accident. This concept also applies if the employee broke another law or strict company policy when the injury took place.
Finally, workers’ compensation will not be dispensed if the injury was self-inflicted. Most of the time, it is obvious to tell this, although sometimes the incident is evaluated to be sure. If any of the noted conditions apply to the workplace incident, then there is a good chance that a workers’ compensation claim would be denied and no funding dispensed.
What Types of Incidents Are Covered by Workers’ Compensation?
If none of the previous conditions or circumstances apply, then the workers’ compensation program covers the incident. This may sound overly simple and it was designed to be for a reason. The workers’ compensation program was designed to aid employees in the wake of an injury that was caused by accident or carelessness on the part of the employer or employee.
In essence, it doesn’t matter who or what caused the workplace injury, it only matters that the injury was sustained while on the job and while the employee was working. Whether it was carelessness on the part of the employee because he or she was not paying proper attention or it was because the employer failed to create safe conditions, if the employee was working, compensation should be granted. Thus the only two requirements for workers’ compensation are being on the jobsite and working at it.
Of course, by definition, if the injury was not severe enough to warrant medical attention, compensation may not be granted because the program was designed to pay for medical expenses. However, if any sort of treatment was necessary, the incident would then be covered by workers’ compensation and funding able to be dispensed to that particular employee.
In the legal world, contributory negligence is a term that refers to how the responsibility of one party or another affects the outcome of a ruling. Under the doctrine of contributory negligence, if a person was injured in part due to his or her own negligence, that is, the carelessness or disregard for safety rulings or procedures, then the injured person is unable to receive damage restitution from another party that caused the incident. For example, if a person is a car accident was found to be negligent, such as if he or she was texting while driving, that person cannot sue the other person in the accident, even if the accident was the other person’s fault.
When it comes to workers’ compensation law, contributory negligence can come into play if the injured employee was found to be in stark disregard for safety protocols. Normally, if the incident was an accident or caused by carelessness, workers’ compensation is still granted. That being said, it is possible that if the injured employee was aware of safety procedures and chose to not follow them, the ability to receive workers’ compensation may be in jeopardy. This is somewhat difficult to prove however, which is why it is typically handled on a case by case basis.
Assumption of Risk
There is another situation that may work to jeopardize a workers’ compensation claim and it is known as assumption of risk. This law doctrine asserts that the injured party in an incident is responsible for the injuries if he or she had knowledge of the risks involved in a given activity. When applied to workers’ compensation law, it means that the company would not be responsible for paying for medical expenses due to the workplace injury because the employee knew the potential risks to the job.
Thankfully for employees, this defense is not commonly held up lately due to other legal decisions and precedents overwriting it. That being said, it can still be a plausible defensive case for the company if the nature of the job itself is indeed hazardous. An example that easily comes to mind is construction, where heavy machinery and physical labor does indeed bring about real risks that may lead to a company claiming this clause. Always speak with a lawyer when faced with such a defensive claim in a workers’ comp case however, as it is often beatable.
Fellow Employee Negligence
There are situations that may arise where a workplace injury is caused not by one’s own negligence, but that of a fellow employee. This is a scenario where fellow employee negligence may come into play. Under this stipulation of the law, the injured employee may not only file for workers’ compensation from the employing company, but also file a personal injury case against the negligent employee. This all operates under the assumption, of course, that the injury took place while on the job.
For example, if a construction worker accidentally strikes another worker with a forklift while on the construction site, the injured worker could file for both workers’ comp and a lawsuit against the other employee and probably both cases to receive compensation. Although this is a fairly common circumstance, different areas do handle it differently and sometimes negligence on the part of the other employee is hard to prove. In obvious cases however, it is certainly a good idea to pursue it in order to receive the maximum amount of financial benefits to help cover the injury’s medical expenses.
How to Tell Whether You’re Covered by Workers’ Compensation
The first thing that you should always do when you are injured on the job is to file a report with the human resources department of your company. Once this report processes, you should receive a phone call from the employer’s workers’ comp insurance company informing you that a claim has been filed. If you have not received this call within a few days, you should follow up with the HR manager to check the status of the filing.
As soon as you initially hear from the insurance company, your workers’ compensation claim is in the process of being considered. You should then hear within a week or so if it was accepted or not and whether you are being covered. Remember that during this time it is still a good idea to keep up to date records of all medical expenses because you will need this information if and when the claim is accepted. Having this information will also help you overturn the denial should that happen for your claim. Odds are, however, that if you meet the criteria listed in the articles above, you are covered by workers’ compensation and would be receiving funds shortly. Having confirmation from the insurance company will guarantee this for you.
How Workers’ Compensation Benefits Are Determined
Under normal circumstances, workers’ comp benefits are meant to cover 100% of the injured employee’s medical costs. It is uncommon, however, to have this funding presented all at once and therefore a determination is made as to how benefits are granted. The payments that are dispensed are based on the employee’s normal weekly wage. The maximum amount one could be granted in workers’ comp is known as the average weekly wage (AWW) and is usually two-thirds of what a person would ordinarily make if he or she was working and not recovering from the injury.
The weekly benefit is then multiplied by the percentage of disability that the person is under, which is based on the most recent doctor report. For example, if a person was considered to be 100% disabled and unable to work at all, the benefits for the week would be 2/3 of the person’s weekly wage. If the person was deemed to be 75% disabled, it would be 3/4 of the 2/3 weekly wage instead. Do note that some of these and all calculations can vary on a case by case basis, but this is typically how it is executed.
Who Pays Workers’ Compensation?
While workers’ compensation operates through the employer, it is actually most commonly not the employing company that makes payments for the program. When a worker is injured while on the job, it is actually the employer’s insurance company that dispenses funding. The company pays for workers’ comp insurance every month so that, in the event of an incident, that insurance company pays for the benefits granted to the injured employee under workers’ compensation. This operates similarly to automobile or any other kind of insurance.
There is an exception to this and it occurs when the employing company insures itself by setting up special accounts to dispense workers’ compensation funds. Currently, this is only a practice that is done in one US state, so it does not apply to Florida. Under Florida law, a company that has more than four employees must carry workers’ compensation insurance. If a company has less than four employees, then they are probably not required to cover workers’ comp at all. Therefore, in this State, it will always be the insurance company that is dispensing workers’ compensation funding.
What Types of Expenses Does Workers’ Compensation Insurance Cover?
Workers’ compensation insurance can vary in terms of the types of expenses that it covers and this variance is based on the type of policy that is purchased. Most plans for workers’ comp insurance cover medical expenses that arise as a result of the original incident. This typically includes doctors’ visits, hospital stays, physical therapy, medication and prescriptions, and more. Most plans also have stipulations in them for disability pay, both long term and short term. These come into effect if the injury is severe enough to keep somebody out of work for an extended period of time.
Although less common, there are some workers’ compensation insurance plans that cover funeral expenses in the event that an employee dies while on the job. These plans not only cover burial costs, but sometimes also grant lost wages to the surviving family members or beneficiaries.
It should also be noted that workers’ compensation insurance is different than general liability insurance and therefore does not cover the kinds of incidents that are covered under that kind of plan, such as customer injuries or slander cases.
Does Workers’ Compensation Insurance Cover Long-term and Permanent Injuries?
The answer to this question depends largely on the type of workers’ compensation insurance plan that the company has purchased and regularly pays into. Baseline, long-term disability and permanent injury circumstances are not covered, however there are some plans that do. It is always best to check with your insurance company to see what kind of coverage you have and if this kind of injury is indeed covered for your workers’ compensation plan, preferably sooner rather than later, in case an incident does arise.
Generally, however, if there is coverage for disability or permanent injury, it will be in one of four kinds. The first is for injuries that are temporary, yet still long-lasting, and it covers them completely. The second kind is for the same kind of injury, but only partially covers it. The third and fourth categories are for total and partial coverage, respectively, for permanent, severe injuries that render employees unable to return to work. Again, it is always best to see what kind of plan your company has, but most of the time, at least partial coverage is included in the majority of workers’ compensation insurance plans.
What if the Injury Was My Fault?
In the vast majority of workers’ compensation cases, the question of fault is an irrelevant one. By its very design, the workers’ compensation program was meant to assist any kind of workplace injury and that holds true to this day. Even if you, the injured employee, were at fault for an injury, you are still eligible to receive benefits through the workers’ compensation program.
That being said, there are some scenarios that your employer or insurance company may try to exploit in order to avoid paying workers’ compensation benefits. One of these is if it was a dangerous job and you knew the risks going into it. This is known as assumption of risk and it does not hold up in court very often, so it is a weak defense meant to scare you off. The only scenario where you would lose a workers’ compensation appeal for being at fault during a workplace injury event is if you were under the influence of drugs or alcohol at the time or were otherwise breaking a law. Barring these circumstances, you can still receive benefits through workers’ compensation, although you may need to fight to have benefits won if your employing company decides to give you a hard time.
Death on the Job
Although it is a rare and extreme circumstance, there are times where a workplace injury will result in death. This tends to happen more commonly in dangerous working environments, but it can occur anywhere, so it is important to know how a death on the job might be handled in terms of workers’ compensation benefits. Obviously, medical expenses aren’t granted to someone that dies while on the job, however, most of the time, there are options for such benefits to be granted to the family and beneficiaries of the deceased individual.
Some workers’ compensation insurance plans have stipulations in them that grant surviving family members funding to cover funeral and burial expenses. Companies that have this kind of plan certainly will grant benefits in the event of a workplace death. If they do not, there is another scenario where benefits can still be granted and that is if it was the negligence of the employer or failure to create a relatively safe working environment that led to the death. In that case, surviving family members can file a wrongful death lawsuit again the company and hope to claim benefits this way.
Suing vs Workers’ Compensation
If you have been injured while on the job and are hoping to collect benefits from the workers’ compensation program, then you are certainly within your rights to do so. However, if you do so, you are unable to sue the employer as well. This is known as the “no sue” rule and applies to individuals collecting workers’ compensation. The idea behind this is that if someone is collecting compensation one way, they should not have it another as well.
That being said, there are a few possible exceptions to this rule, all spawning from the idea that the employer intentionally meant to harm the individual. If it can be proven that the workplace injury was the intended outcome for the company, there is grounds for a lawsuit in the form of what is known as an intentional tort. The most common scenarios in which this type of suit is lobbied are battery, assault, fraud, defamation, invasion of privacy, intentional infliction of emotional distress, and trespassing. Do note however that it must be the employer or higher ranking representative of the company that committed the harmful act, not another employee that would be of an equal rank.
Can You Be Fired for Filing a Workers’ Comp Claim?
Although the laws vary from state to state, in the State of Florida, it is illegal for an employer to fire someone while they are in the middle of a workers compensation claim. This is known as retaliation, in legal terms, and it is a shady tactic that some businesses will try to use to get out of having to pay workers comp claims. They may try to play it off as a normal business decisions, citing that there are “budget cuts” or something of the like, but make no mistake, there is an intent to punish the employee and avoid dispensing workers comp funds behind that.
The exception to this scenario is that if an employee is unable to work for an extended period of time, the company is not legally obligated to hold the position for them. They must however still pay disability benefits and have a position of some kind, albeit not the same exact one, still for him or her upon the employee’s return. Some companies will attempt to use this as a loophole to get out of paying any kind of benefits, but the end result would be the same.
What Happens if Your Claim is Denied?
When you, as an injured employee, report your workplace injury and subsequently file with the employer’s insurance company to attempt to receive workers’ compensation benefits, there is a chance that the claim will be denied. The insurance company may try any number of arguments or potential reasons why the claim was denied, but if it is, they will not grant any benefits to you, at least not without a fight. Thankfully, the situation is far from hopeless if your workers’ comp claim is denied.
After a denial, you can appeal to have that denial overturned. This denial is initially done to the insurance company, although the odds of success are slim since that company would have denied the claim in the first place. More likely than not, you will need to file a workers’ compensation lawsuit in order to see any benefits granted to you. When going through this process, it is highly recommended that you consult with an attorney that is well-versed and experienced in this kind of law in order to grant yourself the best chance possible of winning the case and acquiring the benefits you deserve.
Workers’ Compensation Fraud
Although the workers’ compensation program was designed with good intent, as it is with many such programs, there will always be people that seek to take advantage of it and abuse the system as a result. When this happens in a workers’ compensation case, it is known as workers’ compensation fraud and can be performed from three different parties: the employee, the employer, or the health care professional.
When workers’ compensation fraud is attempted from the employee, it is most likely in the form of a false injury or illness. In this situation, the person will lie about having an injury or illness, or greatly exaggerating one, in order to gain funding. This could also happen if the employee attempts to claim a non work related injury as one and thereby seek compensation they don’t deserve from the company.
If the employer commits workers’ compensation fraud, it is likely to receive lower premiums on workers’ compensation insurance. By lying about job safety and protocols that should be in place, or by misclassifying employees into categories that would make them eligible for lower insurance rates, they are committing fraud as well. Finally, health care providers can commit workers’ comp fraud by prescribing more treatment than is necessary in order to receive more of the individual’s and company’s funding.
In whichever form it manifests as, workers’ compensation fraud is never acceptable and incurs harsh fines and criminal prosecution from the government if it can be proven.
Workers’ Compensation Stipulation Agreements
When a workers’ compensation case is being processed, there are other options for how the case will end than simply accepted or denied. The other two options are settlements and stipulations and, while they are somewhat similar, there are key differences that are important to understand. A settlement is an agreement to close a workers’ compensation case by accepted a single large sum instead of ongoing payments. This is not a bad idea, in some situations, but it does not protect one in the future, especially if the injury is going to have long-lasting effects.
A stipulation agreement, on the other hand, does help ensure that benefits could be granted in the future. By definition, a workers’ compensation stipulation agreement temporarily closes the workers’ comp case, but leaves it open to be reassessed within five years to determine if additional benefits are required. This is done after the initial benefits are granted. The main appeal of a stipulation is for situations when the workplace injury could have long-lasting effects or least to a partial disability and it leaves it open for the individual to receive benefits in the future to cover ongoing medical expenses.