Filing a Worker’s Compensation Claim: An Overview
Worker’s compensation was established to provide compensation for workers who have been injured in the course of their employment without having to sue their employers. The elimination of the litigation process avoids having to prove the liability of the employer. Worker’s comp is thus a no-fault system. Although it has prevented the vast majority of potential employer-employee lawsuits, the worker’s comp process can be contentious, and if you’re the injured worker, you may have to fight to receive the compensation you deserve.
Your Employer’s Coverage
Although most employers are required to carry worker’s compensation insurance, there are some exceptions for companies with only a handful of employees. Those employers who are exempt from coverage, however, may opt in under certain circumstances, thus avoiding the possibility of a lawsuit. It is required that the employer conspicuously post worker’s comp information at the workplace, and you should easily know your employer’s status.
Your Eligibility
The general rule is that you must be an employee to be covered, and although this may seem to be a straight-forward matter, there are distinctions and subtleties that can cloud the picture. One of the primary issues is the categorization of a worker as an independent contractor, not covered, versus an employee, who is covered. While this can be a complex question subject to legitimate dispute, some companies intentionally claim workers as non-employees to avoid paying claims.
Other issues of coverage arise based the type of work you do. Certain workers may be exempt from coverage, such as:
- Agricultural workers
- Domestic workers
- Leased or loaned workers
- Casual or seasonal workers
Importantly, your injury or illness must be work related for you to be eligible for coverage. In most cases this is obvious but not always. Whether an injury sustained in commuting to work, on one’s lunch break or while involved in a company sponsored social event are covered, for example, are all areas that may depend on the specific facts and circumstances surrounding the event.
Procedural Issues
A threshold issue in worker’s compensation claims is notice; that is, you as the injured worker must inform your employer of your injury as soon as possible. A work accident can be obvious and all are aware immediately but some, such as an occupational disease acquired from long-term exposure to a toxin, may not be so readily apparent. You should notify your employer as soon as possible and be aware that there are deadlines for filing a claim; if you are outside that time frame, your claim can be denied.
Disputed Claims
The worker’s comp insurance carrier or your employer can weigh in and contest part of or your entire claim. The area of dispute can be on matters such as the severity of your injury, the scope of treatment that you are seeking, whether you can work during your treatment, whether the injury was work-related or whether this is a pre-existing injury.
If you disagree, you have the right to appeal the decision. In some instances, the basis for the denial is simply the lack a certain document and may be simply corrected. In any event, it is important that you file your appeal within the established guidelines; an untimely appeal may not be heard. It may be in your best interest to consult a worker’s compensation attorney to assist you in fully understanding your rights.
