Annually there are about 3 million work-related accidents that occur in private industry. Approximately one-half are severe enough to require ongoing medical treatment, job duty restrictions, or time off from work. The medical approach to the actual care of the physical accident should not vary by location, but the regulations governing the administration of workers’ compensation claims can vary widely from state to state. This article will hopefully provide you with an overview of the workers’ compensation system and your responsibilities.
Overview of most common types of injuries and higher risk occupations
The most common types of injury cared for in workers’ compensation are sprains, strains, and ligament tears. Back (36%), shoulder (12%) and knee (12%) are the most common body areas that are injured. Most injuries are cared for by either an occupational medicine specialist or a primary care physician who accepts workers’ compensation injuries (more about this later).
Occupations at highest risk for physical injury are construction laborers, nursing/homecare aides and janitors/cleaners. There has been a massive effort in the manufacturing sector to make the workplace safer and this has translated to fewer reported factory accidents in recent years.
How to file a claim under the Workers’ Compensation System
All states have regulations requiring employers to carry workers’ compensation insurance that provides cash benefits and medical care for workers who are injured or become ill as a direct result of their job. Employees are not required to pay for the costs of this medical care or the cost of weekly cash benefits if the person cannot work. These benefits are paid through an insurance company or third-party administrator. The amount of medical reimbursement to medical providers and facilities and your weekly cash benefit also varies by state. Each state also has a workers’ compensation board that oversees this legal process. In case of long-term physical or psychological impairment that results from an injury, there are regulations that define this process.
Workers’ compensation is a no-fault system. The amount that a claimant receives is not decreased by his/her carelessness, nor increased by an employer’s fault. However, in most states including New York and Pennsylvania a worker loses his/her right to workers’ compensation benefits if the injury results solely from intoxication from drugs or alcohol, or from the intent to injure him/herself or someone else at the workplace.
If you are injured on the job, you must follow these simple steps:
1. It is important that you report your accident to your supervisor or company management as soon as possible. This will get the incident reported and the process started. Failure to do this may lead to a dispute by the employer or the carrier about whether the accident occurred at the workplace. For emergencies, seek care and then notify your employer as soon as possible. An injured employee who fails to inform his or her employer verbally or in writing within 30 days after the date of the accident may lose the right to workers’ compensation benefits.
2. Seek out either first aid or other necessary medical treatment as soon as possible. In New York State, the treating healthcare provider must be authorized by the Workers’ Compensation Board, except in emergency situations. In Pennsylvania, each employer is required to establish a panel of primary care and specialty providers in the area where the patient may seek care. Employers will often have signs posted around the workplace about how to report an injury and what to do in an emergency.
3. The medical professional who sees you initially will take a complete history about the injury and other pertinent health information, such as history of past injuries, surgeries and allergies. The provider is required to document his/her history and findings, as well as offer an opinion about whether the situation is work-related. Doctors will not document any of your medical history if it is not related to the injury. If the injury is accepted as being related to employment, therapies, diagnostic testing and medication will be covered 100%.
4. Many states have allowed employers to work with insurance carriers in establishing preferred provider organizations (PPO’s), designated pharmacies, diagnostic centers and other network services. If you require diagnostic testing, check with your human resources department or the company’s workers’ compensation carrier before scheduling. If you schedule yourself and it is “out of network,” your workers’ comp carrier may refuse to pay, as well as your medical insurance company.
5. The employer and its insurance carrier have the right to dispute the validity of a claim. The time of reporting, the results of the medical exam and onsite investigation, including interviewing your co-worker(s) who may have witnessed the event, are all used to investigate a disputed claim. You will be interviewed by a case manager from the carrier or be required to complete various forms to describe your injury, physical factors or circumstances that may have caused the accident.
6. If your injury or illness is significant enough that during your recovery period you are unable to return to a modified-duty position or required to be restricted to home, except to go out to doctors and therapies, you will be compensated for this lost time but not at your regular salary. Every state has an established maximum level of reimbursement. Generally, it is 66% of your salary up to maximum cap. For many of us, this compensation is far below our regular salary.
Every employee needs to know about how a workers’ compensation injury is handled in his/her state of employment. If you live in another state from that of your employer, the workplace address determines the regulations that will be applied to your claim. There are state websites available for employees to provide this information in an easy-to-understand format.