THIS IS HOW YOUR WORKERS COMP CLAIM SHOULD WORK
You are injured. You immediately report your injury to your employer. Your employer reports your injury to your employer. If your injury does not require emergency treatment at a hospital, you are usually told to go to a walk-in clinic or urgent care center. You are NOT entitled to choose your own physician, except in limited circumstances. Many times you will be asked to take a drug test on the day of the accident. If you refuse and your employer has a “drug free workplace” policy in place, you risk losing your benefits. If your drug test comes back positive, then you may also have a problem that will jeopardize your benefits, but that depends on the circumstances.
Once you have been seen by your authorized treating physician, you will follow the course of treatment until you reach MMI. During this period, you will pay nothing for your medical care. Everything is covered, even your prescriptions and your transportation (you are entitled to a medical mileage reimbursement, or actual transportation provided by the insurance carrier). At some point, your physician will place you at Maximum Medical Improvement. After that, you will have a $10 co-pay for all treatment visits. You are entitled to future medical care following MMI as long as your industrial workplace accident is and remains the Major Contributing Cause of the need for the treatment; however, you MUST receive a benefit or treatment at least once a year, or your claim may be closed and you may be barred by the Statute of Limitations from ever making a claim for benefits under this accident again.
If you are unable to work at all following your accident, you should be entitled to Temporary Total Disability (TTD) benefits. If you are released to work with restrictions (“light duty”), then, if your employer can accommodate you, you must return to work. If your employer cannot accommodate you, then you are entitled to Temporary Partial Disability (TPD) benefits.
All of your indemnity (or disability) benefits are based upon your Average Weekly Wage (AWW) at the time of the accident. Your AWW is calculated by taking your pre-tax wages from all “covered” employment for the 13 weeks prior to the date of accident, adding them up and dividing them by 13.
You are entitled to TTD or TPD, when you are unable to work due to your accident related injuries, up to the point you reach MMI. At MMI, your temporary benefits end. If you have a permanent injury, your physician should address that an assign you a Permanent Impairment Rating (PIR). If you have a PIR, you will be entitled to Impairment Benefits based upon the percentage of your PIR. If you are unable to return to work at even a sedentary job, then you may be entitled to Permanent Total Disability (PTD) benefits.
At some point during the process, but usually after you have reached MMI, the carrier will approach you to settle your case. The settlement value of your case is usually based upon the insurance carrier’s exposure to pay future benefits. In other words, it’s based upon how much you will cost them in the future. Many times, if you are still employed with the same employer, they will ask you for a voluntary resignation as a condition of settlement. You do not have to settle your case, and neither do they. Not all cases settle. The decision to settle is a very personal one and will depend on a lot of factors that are specific to your life.
That’s Workers’ Compensation in a Nutshell. There are obviously many things that can happen along the way that make matters much more complex, but the above process is typical for most claims that are straightforward.