Workers' compensation represents a foundational element in the employment relationship, often characterized as a "grand bargain" between employers and employees. This framework ensures that employees who suffer work-related injuries or illnesses receive timely medical care and wage replacement benefits without the need to establish fault, while employers gain protection from potentially costly and unpredictable civil litigation. In this guide, we will give you a general understanding of workers' compensation, including who is covered, what benefits are available, how to pursue your claim, and what to do if your claim is denied.

Important: Before we begin, it should be noted upfront that, unlike many workplace regulations, workers' compensation is not mandated or regulated at the federal level, except for federal employees and certain other specific groups, which means that each state has its own workers' compensation laws and system, resulting in significant variations in coverage, benefits, and procedures from one state to another. As such, when reading this guide, it's essential to keep in mind that while we present general principles of workers' compensation, the exact rules that apply to you depend on your state's laws, with some states having broader coverage or more generous benefits, while others may have stricter eligibility requirements or different procedures for filing claims.

Eligibility for Coverage 

Let's begin by exploring who is entitled to receive workers' compensation coverage:

• Full-Time Employees: With the exception of Texas, all states require that covered employers (i.e., those who are not exempt under state law due to being sole proprietors, having a small number of employees, or other state-specific exclusions/exemptions as might be the case with undocumented workers, minors, and family members) must provide workers' compensation coverage for their full-time employees. While that may seem straightforward, there are state variations regarding what qualifies as "full-time" employment, and how long an employee must be employed before being covered.
• Part-Time Employees and Seasonal Workers: Coverage for part-time and seasonal workers varies widely by state. As mentioned above, some states mandate coverage for part-time employees only if they work a minimum number of hours per week or have been employed for a particular duration. Seasonal workers might also be covered depending on the nature of their employment and the industry in which they work. For example, in New York, part-time workers must be covered if they work consistently, regardless of the total hours, while in other states, coverage might only apply if they exceed a specific hourly threshold.
• Independent Contractors: Generally, independent contractors need not be covered under workers' compensation laws. However, who is considered truly "independent" for these purposes is dictated by state law, not merely by the contract between the employer and the worker. Additionally, in some states, even workers who are unambiguously independent contractors must be covered if they work in specific high-risk industries, such as construction, trucking, or logging, where the nature of the work poses significant hazards.
• Special Situations: In the following situations, there is even more state variation regarding workers' compensation coverage than in the previously mentioned categories: whether and when family members need to be covered, the eligibility of undocumented workers, the coverage of minors, and the inclusion of volunteers, interns, and individuals participating in work-study programs.

Types of Injuries and Illnesses that are Covered

Workers' compensation is meant to cover injuries and illnesses that arise out of and in the course of employment. This means that if an injury or illness is directly related to your job duties or occurs while you are performing your work, it should be covered under one of the following categories: 

• Work-Related Injuries: Work-related injuries include a broad range of physical harm that occurs as a direct result of your job. These injuries can be sudden, such as a fall or a machinery accident, or they can develop over time, like repetitive strain injuries from prolonged tasks. For instance, an office worker developing carpal tunnel syndrome from years of typing, or a construction worker injuring their back while lifting heavy materials, are examples of injuries that are typically covered. Furthermore, for the most part, any injury that happens while performing your job duties, regardless of whether you are on the employer's premises, is covered. For example, if a delivery driver is injured in a car accident while making deliveries, that injury is generally considered work-related.
• Occupational Diseases: Occupational diseases are illnesses that develop due to exposure to harmful conditions or substances in the workplace, such as respiratory diseases from inhaling toxic fumes, hearing loss from prolonged exposure to loud machinery, or skin conditions from handling hazardous chemicals. The recognition of occupational diseases can vary significantly by state, and some states have specific lists of diseases presumed to be work-related, which makes it easier for workers in those states to obtain benefits, whereas, in others, the burden of proof is on the employee to demonstrate that the illness is directly related to their job.
• Pre-existing Conditions: While workers' compensation does not generally cover pre-existing medical conditions (i.e., those that existed before you began your current job), they may cover the aggravation or worsening of a pre-existing condition if your work activities directly caused or significantly contributed to its deterioration. This means that if you had a pre-existing condition and your work duties exacerbated or made it worse, you might be eligible for workers' compensation benefits. For example, if you had a history of back pain and your job required heavy lifting or prolonged sitting, and your back pain worsened due to these activities, you could potentially be entitled to benefits, although you will generally need to provide medical evidence, such as doctor's reports or expert opinions, that clearly demonstrates the connection.

Compensation and Benefits 

Now that we have discussed who must be covered, we will move on to what must be covered. 

Medical Benefits: A central component of workers' compensation coverage is the provision of medical treatments and equipment necessary to address a work-related injury or illness and restore the worker's health, enabling their return to work. This includes:

• Physician visits, including consultations with general practitioners, specialists, and surgeons
• Hospital stays for inpatient care, surgeries, and emergency room visits. 
• Medications 
• Physical and occupational therapy as necessary to restore the injured workers' functions and mobility, and to assist them in adapting to work tasks and activities of daily living. 
• Medical equipment, which can include anything from crutches, to wheelchairs, prosthetics, and other necessary devices. 
• Diagnostic tests such as X-rays, MRIs, blood tests, and other imaging studies.  

Wage Replacement Benefits: Another core component of workers' compensation is to provide wage replacement benefits to employees who are unable to work due to a work-related injury or illness, ensuring they receive a portion of their lost income during their recovery (or, in some cases on a permanent basis if they are unable to return to work). Wage replacement benefits may include:

• Temporary Total Disability (TTD) Benefits: TTD benefits are paid to employees who are entirely unable to work due to their work-related injury. These benefits typically represent a percentage of the employee's average weekly wage and continue until the employee can return to some type of work, even if it's modified or light duty, or until they reach maximum medical improvement (MMI).
• Temporary Partial Disability (TPD) Benefits: TPD benefits are available to employees who can return to work after an injury but cannot earn their full pre-injury wages due to limitations caused by the injury. These benefits compensate for a portion of the difference between the employee's pre-injury earnings and their current reduced earnings.
• Permanent Partial Disability (PPD) Benefits: PPD benefits are awarded to employees who have sustained a permanent impairment from a work-related injury that affects their ability to work. The amount of compensation is determined by factors such as the severity of the impairment, often expressed as an impairment rating, the employee's occupation, and their potential for future earnings. 
• Permanent Total Disability (PTD) Benefits: PTD benefits are provided to employees who are permanently and totally disabled as a result of a work-related injury and are unable to return to any type of gainful employment. These benefits typically provide ongoing financial support for the employee's lifetime.

Other Benefits: Besides the medical and wage replacement benefits mentioned above, there are numerous other benefits that one may be entitled to based on their specific circumstances, such as vocational rehabilitation, dependent care benefits, home and vehicular modifications, and case management services.   

Reporting an Injury and Starting the Workers' Compensation Process

Once you are injured or become aware of a work-related injury or illness, it's essential to act quickly to protect your right to workers' compensation benefits. The process involves several key steps, starting with notifying your employer.

Step 1: Report the Injury to Your Employer
It's of utmost importance to report your injury or illness directly to your employer as soon as possible. This is the first and most essential step, as your employer is responsible for notifying their workers' compensation insurance carrier, which initiates the formal claims process. Failure to report promptly can complicate your claim or even result in its denial.

Step 2: Understand Your Role in the Claim Filing Process
While the responsibility of officially filing the claim usually lies with your employer, you play a critical role in providing necessary information and ensuring that all documentation is accurate and timely. After reporting your injury, you may be required to complete a formal claim form, which, based on your state, may be provided by your employer or the state's workers' compensation board, and in which you will need to fill out detailed information about the incident, such as the nature of the injury, how the injury occurred, and any medical treatment you've received.

Step 3: Know the Deadlines
The deadlines for reporting an injury and filing a workers' compensation claim vary widely depending on your state. These deadlines, known as the "statute of limitations," range from as short as 30 days to as long as two years. It is vital to be aware of the specific deadlines that apply in your state, which can be influenced by several factors, such as:

• Date of Discovery: For conditions that develop gradually, the timeline for filing a claim may begin from the date you first became aware of the condition and its connection to your work.
• Employer's Knowledge: If your employer was already aware of the injury or illness, this could impact the filing deadline or even satisfy the notification requirement in some cases.
• Nature of the Injury: Traumatic injuries may need to be reported within 30 days, while occupational diseases might allow for a longer reporting period

What to Do if Your Claim Is Denied

If your workers' compensation claim is denied, either in whole or in part, by the employer's insurer, you should neither be surprised nor discouraged. While there are valid reasons for denying claims, insurance companies may also deny or reduce claims due to factors that impact their financial bottom line. When your claim is denied or reduced, the denial notice must specify the reasons for the decision (grounds such as "we like money" are, of course, not valid).

Denials (or partial denials) of workers' compensation claims can occur for various reasons, including:

• Questions About Work-Relatedness: Employers or insurers might claim that the injury did not occur at work or is not as severe as reported. This can lead to either a full denial or a partial reduction of the benefits awarded.
• Administrative Errors: Mistakes such as incorrect or incomplete forms, missing documentation, or failure to meet filing deadlines can result in denials. These errors might lead to partial denial if only specific parts of your claim are contested.
• Pre-Existing Conditions: If the insurer argues that your injury is related to a pre-existing condition rather than a work-related incident, this could result in a denial or reduced benefits.
• Disputes Over Medical Evidence: There may be conflicting opinions on the severity of your injury, whether it's work-related, or whether you have reached maximum medical improvement (MMI). The insurer might argue that the medical evidence doesn't support the level of benefits claimed.

If your claim is denied or partially denied, several options are available to challenge the decision:

• Internal Appeal with the Insurer: Some states require or allow an internal appeal process before escalating the case. This involves submitting additional documentation or evidence directly to the insurer to reconsider their decision. It's a more informal step, but it can sometimes resolve disputes without further escalation.
• File a Formal External Appeal: If the internal appeal doesn't resolve the issue, or if your state allows you to bypass this step, you can file a formal appeal with the state's workers' compensation board or a similar administrative agency. This formal appeal must be filed within a specific timeframe, typically ranging from 30 to 90 days from the date of the denial.
• Administrative Hearings: After filing an appeal, you will likely be scheduled for an administrative hearing. During this hearing, you will present your case before an administrative law judge (ALJ) or a workers' compensation appeals board. You'll have the opportunity to submit additional evidence, call witnesses, and argue why the denial or partial denial should be overturned. The judge or board will review the evidence and issue a decision.
• Higher-Level Appeals: If the administrative hearing doesn't result in a favorable outcome, you may have the option to appeal the decision to a higher court, such as a state appellate court. These higher-level appeals are typically more formal and involve a legal review of the case rather than a re-examination of the facts. The appellate court will look for legal errors in the administrative decision and determine whether to uphold or overturn the ruling.

Understanding workers' compensation, from filing a claim to knowing your rights, can be challenging, especially when you're focused on recovering from an injury or illness. Through AAL's directory, you can find experienced attorneys with extensive experience in practicing workers' compensation law who are ready to help, and who can assist you at every step, from pursuing your claim to appealing a denial, and ensuring that you receive the benefits you're entitled to.