Workers’ Comp Claim: What To Do After Getting Injured On The Job

According to the Bureau of Labor Statistics, the private industry reported 2.7 million non-fatal workplace injuries and illnesses in 2020 and another 4,764 fatal injuries in the same year. If you get injured on the job, you may be entitled to monetary compensation or medical care benefits through your employer’s workers’ compensation insurance.

Read on to learn how workers’ compensation works, what you should do after sustaining an injury or illness at work, and the benefits you may claim on the insurance.

Workers’ compensation insurance in a nutshell

Workers’ compensation or workers’ comp is an insurance cover that provides cash or medical care benefits to employees who get injured or ill on the job or as a direct result of their job. The employer provides and pays for the workers’ comp insurance, which guarantees coverage for workplace injuries and illnesses. In return, workers’ comp protects the employer from possible lawsuits related to workplace injuries. The employer’s insurance carrier settles the claims.

Workers’ comp claims are processed at the state level through the Workers’ Compensation Board or Commission. And although the policy’s rules vary between states, workers’ comp generally works in the same way across the US.

The claimant gets compensated if the insurance carrier determines that the reported injury or illness is indeed work-related. The insurer generally reimburses or pays the claimant for lost wages, medical care, rehabilitation therapies, and disability. No one party is held at fault in workers’ comp claims. However, the insurer may reject claims that do not fall under workers’ comp coverage. And claim disputes can escalate to court cases where a judge decides over the eligibility of a claim or benefits.

What’s covered under workers’ comp?

Before you make a workers’ comp claim, it’s important to understand the benefits you might actually be entitled to and what the workers’ comp won’t cover. Clarity on the scope of workers’ comp will save you a lot of time and help you make a valid claim.

What’s Covered?

Medical treatment for the injury or illness.
Temporally and permanent disabilities (separate from Social Security Disability Benefits).
Vocational rehabilitation, usually for training the claimant on coping with the long-term effects of the injury or illness at work.
Monetary compensation for lost time and wages during treatment, recovery, and time off work.
Mileage covered in injury or illness-related travels.
Survival benefits that financially support the employee’s family in case of a fatality. This covers loss of income and funeral expenses.

What’s Not Covered?

Workers’ compensation insurance only covers injuries and illnesses that occur “within the scope of employment.” This means that you’re entitled to workers’ comp benefits if your injury or illness occurs in your place of work, during a work-related activity, or is a direct result of your job. The scope of employment may include remote work, vocational training, taking work-related calls, and off-duty business travel.

Here are common situations that fall outside the scope of employment and other factors that might exclude you from claiming workers’ comp:

Commuting to and from work or for personal reasons.
Recreational activities (unless the activity was compulsory, occurred on business premises during working hours, or your attendance benefited the employer).
Voluntary participation.
Under the influence of alcohol or illegal drugs (unless you can prove that the injury resulted from an accident or incident that was not your fault).
Workplace horseplay and fights fall outside the occupational scope but may be covered if related to work or tolerated by the employer. Innocent bystanders may also be covered.

How to file a workers’ compensation claim

If you’ve suffered a work-related injury or illness, you must follow the laid out procedures to get workers’ comp benefits. Failure to do so could result in a rejected claim. Here is a step-by-step guide on what you need to do after a work-related injury or illness:

1. Get Immediate Medical Attention

First things first, seek medical attention as soon as possible after an injury or becoming aware of illness symptoms. Prompt medical attention will help relieve the injury or illness and provides a detailed medical description of your situation, which you can use to strengthen your case.

2. Report The Injury Or Illness To Your Employer

Some state laws require that you notify your employer about sustained injuries or illness as soon as practically possible, while others have specific deadlines ranging from a couple of days to three months. Check what your state’s Workers’ Compensation Board/Commission says about when you can file a claim. But it’s advisable to report an incident as soon as possible to preserve your compensation eligibility.

3. Fill Out The Necessary Paperwork
   After notifying the employer about your injury or illness, they’ll provide you with a claims form to fill out. The form will collect details about your injury or illness, including how and when it occurred, the nature of the illness or injury, and the treatment received. Having done that, your employer will submit the claims form to the insurer along with any other supporting documentation. Your doctor may also have to submit a medical report stating your injuries and health condition.
4. Wait For The Insurer’s Verdict

After receiving the claim, the insurer will conduct their own investigation into the case. This should take a few days or weeks, depending on the claim’s complexity. And based on their findings, the insurer will either approve or deny your claim.

If the claim is approved, you’ll receive the benefits either in a lump sum settlement or installment. But if the claim is denied, you can present the insurer with new evidence or information and request a reconsideration. The other option is to file a formal appeal through your state’s Workers’ Comp Board/Commission if you feel that the denial was unfair or unjust.

5. Return To Work

You can return to work once you are fully recovered, provided you can still work in the same position or organization. But you may have to arrange a return-to-work program with your employer if your injuries or illness will affect how you work. In case your injuries prevent you from returning to work altogether, workers’ comp may support vocational training for a new job position and fair compensation for all the time you’ll miss work.

Bonus tips for claiming workers’ comp

The smallest mistake when filing workers’ comp, such as delays and providing inaccurate, inadequate, or conflicting information, can invalidate the claim. Here are some quick tips for ensuring your claim gets approved and preparing you for any conflict with the employer, insurer, or court:

Be sure not to miss any deadlines, paperwork, appointments, or legal proceedings.
Keep your story straight, and be wary of surveillance and manipulative private investigators.
Get a second opinion on the medical examinations and treatments.
Gather every document or evidence that supports your case (receipts, journals, bank statements, photos, work restriction slips, medical bills, etc.).
Consider hiring a workers’ comp lawyer to guide you through the claiming process and protect your rights.

You have to prove to the employer and insurer that you deserve compensation after suffering an injury or illness at work. Unfortunately, workers’ comp claims can get complicated, especially when eligibility for compensation comes into contention. So, understand what you are getting into and prepare accordingly, ideally by seeking legal counsel or having an attorney by your side.