Q: How do I know whether I am covered by workers' compensation?
Q: Who pays workers' compensation benefits?
Q: Does an injury have to have a definite date of onset in order to be covered?
Q: Can I be treated by my own doctor and, if not, can I trust a doctor provided by my employer?
Q: How do I know whether I am covered by workers' compensation?
A: Determining whether or not you are covered by workers' compensation can sometimes be quite complicated. Generally, however, there are two main factors that determine your status: first, whether you are an employee, and second, whether your injury occurred as a result of your employment. It should be noted that neither of these factors is an absolute guarantee that you will be covered by workers' compensation. For example, depending on the state, some employees (for example, agricultural workers) are not covered by workers' compensation. Also, if you were intoxicated at work or intentionally injured yourself, you might not be covered by workers' compensation. When in doubt, you should contact an experienced workers' compensation attorney, who can advise you of your rights.
Q: If an employee is receiving workers' compensation benefits, but returns to work, does the employee still get to receive workers' compensation benefits?
A: The answer to this question is "maybe." If the return to work enables the employee to receive wages equal to or greater than he or she was earning prior to the injury, then it is likely benefits will be stopped. If, however, the employee is still experiencing a wage loss due to his or her injury, he or she may continue to receive wage loss benefits, although the benefits will most likely be for a lesser amount.
Q: Can an employee recover workers' compensation benefits, no matter what he or she did, because it is a "No-fault" system?
A: No. Although most injuries are covered by workers' compensation, that does not mean that employees have free reign to injure themselves, or act in any manner in which they choose, and then collect benefits. Generally, if an employee sustains injures as a result of intoxication or illegal drug use, benefits may not be payable.
Q: Can an employee recover workers' compensation benefits, even if he or she was not actually at the workplace when injured?
A: The answer to this question will depend on the laws in your particular state, and the facts of the specific case. Generally speaking, if the injury "arises out of" and occurs "within the scope of employment," it is covered. For example, if an employee is a traveling salesperson and is injured in the hotel where he or she is staying for business purposes, compensation may be appropriately paid.
Similarly, if an employee is running an errand that takes him or her outside of the workplace, at the request of the employer, compensation benefits may be payable if an injury occurs in the course of running that errand. If the employee is on a business errand, but has stopped or deviated from that errand for personal reasons, then a closer examination of the rules and facts is necessary.
Finally, employees injured while attending an employer-sponsored recreational event, like a company picnic or outing, may be able to receive workers' compensation benefits even though they were not physically on the employer's premises at the time of the injury.
Q: Who pays workers' compensation benefits?
A: In most states, employers are required to purchase insurance for their employees from a workers' compensation insurance carrier. In some states, larger employers who are clearly solvent are allowed to self-insure, or act as their own insurance companies. When a worker is injured, his or her claim is filed with the workers' compensation carrier, or the self-insuring employer, who pays medical and disability benefits according to a state-approved formula. It is noteworthy that some smaller companies (with fewer than three or four employees) are not required to carry workers' compensation insurance at all.
Q: Does an injury have to have a definite date of onset in order to be covered?
A: Not necessarily. Your injury does not need to be caused by one specific incident such as a fall from a ladder. Many workers, for example, receive compensation for repetitive stress injuries, including carpal tunnel syndrome and back problems, which are caused by overuse or misuse over a long period of time. You may also be compensated for some illnesses and diseases that are the gradual result of work conditions, for example, heart conditions, lung disease and stress-related digestive problems.
Q: Can I be treated by my own doctor and, if not, can I trust a doctor provided by my employer?
A: In some states, you have a right to see your own doctor if you make this request in writing before an injury occurs. More typically, however, injured workers are referred to a doctor recruited and paid for by their employers, or their employers' insurance carriers.
The doctor's report will have a big impact on the benefits you receive. It is crucial that you tell the doctor the truth about both your injury and your medical history (your benefits may be denied based on fraud if you don't); be sure to clearly identify all possible job-related medical problems and sources of pain. In short, this is no time to downplay the presence of a pain. Keep in mind that a doctor paid for by your employer's insurance company is not necessarily your friend. The desire to get future business may motivate a doctor to minimize the seriousness of your injury or to identify it as a pre-existing condition.
Q: If an insurance company's doctor treats me initially, do I have the right to see my own doctor at some point?
A: State workers' compensation systems establish technical and often tricky rules in this area. Often, you have the right to ask for another doctor at the insurance company's expense if you clearly state you have a problem with the one the insurance company provides, although there is sometimes a waiting period before you can get a second doctor. Also, if your injury is serious, you usually have the right to a second opinion. In some states, after an insurance company's doctor treats you for a certain period (90 days is typical), you may have the automatic right to transfer your treatment to your own doctor or health plan with the cost being paid for by the workers' compensation insurance company. Don't hesitate to go to a doctor who specializes in your injury or illness.
