Understanding the workers’ comp system is key to receiving all the benefits to which you're entitled.
If you get hurt or become sick on the job, you probably have the right to compensation in the form of workers' comp benefits. In fact, workers' comp may be your only remedy for work-related injuries. Here's what you need to know about applying for workers' comp benefits in 2023.
What Is Workers' Compensation?
How Much Are Workers' Comp Benefits?
Am I Eligible for Workers' Comp Benefits?
Steps to Follow If You're Injured at Work
Is My Injury Covered by Workers' Comp?
Applying for Workers' Comp Benefits
Appealing a Workers' Comp Decision
Types of Workers' Comp Benefits
Hiring a Workers' Comp Lawyer
What Is Workers' Compensation?
Workers' compensation is a system created by state law to provide benefits to employees who sustain on-the-job injuries, while also protecting employers from the liability of employee lawsuits. Under the workers' comp system, employees are entitled to lost income and medical expenses when they suffer a work-related injury or illness, regardless of who was at fault. In return for these benefits, employees give up the right to sue their employers in court for workplace injuries.
Workers' comp laws can differ substantially from state to state, so it's important to be familiar with the laws in your particular area. But there are many similarities among the states as far as who is eligible for workers' comp, what injuries are covered, the types of benefits available, and the process for making a workers' comp claim.
How Much Are Workers' Compensation Benefits?
Benefit amounts vary from state to state, but it's fairly typical for states to provide two-thirds of your previous wages in benefits, subject to a weekly cap. In addition, workers' comp benefits can cover the cost of your medical care.
A number of factors determine exactly how much you'll receive in workers' comp, and for how long. They include:
- whether and for how long you're unable to work
- the severity of your illness or injury, and
- the rules in your state.
As you'd expect, temporary injuries are typically worth less than permanent ones. Likewise, if your injuries have left you "totally disabled" (that is, completely unable to work), you'll receive more than if you're only "partially disabled" (still able to perform a less demanding job).
Am I Eligible for Workers' Compensation Benefits?
To be eligible for workers' comp, you must meet your state's deadlines for reporting your injury and filing a workers' comp claim. In addition, all of the following must be true:
- You must be an employee.
- Your injury or illness must be work-related.
- Your employer must have workers' comp insurance.
- Your job must be the type that is covered by workers' comp.
Below we'll discuss these criteria in more detail.
You Must Be an Employee
The workers' comp system is designed to protect employees who suffer work-related injuries. It does not protect workers who are not employees, such as independent contractors and volunteers.
However, just because you are called an independent contractor doesn't mean you are one. Whether workers are employees or independent contractors in the eyes of the law typically depends not on what they are called or how they are classified for tax purposes, but on how much control they have over their work.
Volunteers generally aren't entitled to workers' comp coverage, but some states make exceptions for certain volunteers, such as volunteer firefighters or police officers.
Your Injury or Illness Must Be Work-Related
To recover workers' comp benefits, you need to show that your injury or illness is "work-related." An injury generally is considered work-related if you were doing something for the benefit of your employer, and you were injured or became ill as a result. The injury need not take place at the worksite, but must take place during the course of your employment.
An injury typically is not considered work-related if:
- the injury occurred during your lunch break, unless you were eating lunch on the company premises, or
- the injury happened during your commute to or from work, unless you are driving a company car, are required to bring your own car for business use during the workday, were running special errands for your employer, or were on a business trip.
Example. James, a salesperson, suffers an injury from a car accident while driving from his office to his client's place of business. James will likely be covered by workers' comp because his trip was business-related and occurred during the workday. However, if James was injured while driving home in his car after his workday was over, he probably wouldn't be entitled to workers' comp.
Your Employer Must Have Workers' Compensation Insurance
The vast majority of employers are required by state law to carry workers' comp insurance, but there are exceptions. For example, very small employers (between two to five employees, depending on the state) are not required to offer workers' comp coverage in some states. A few states don't require charities to purchase workers' comp insurance. Texas is the only state that does not require private employers to purchase workers' comp insurance.
If you are injured on the job and your employer doesn't have workers' comp insurance despite a state requirement, you can file a personal injury lawsuit against your employer in civil court. Some states have an uninsured employers fund, and in those states, you can make a claim against the state fund instead.
Your Job Must Be Covered by Workers' Comp
Certain types of workers are exempt from or otherwise not covered by state workers' comp coverage. While these job categories vary from state to state, the most common exceptions to state workers' comp include:
- domestic workers, such as housekeepers or caregivers
- some agricultural workers and farmworkers
- casual or seasonal workers
- real estate agents
- members of the clergy
- taxi drivers, and
- federal employees, railroad workers, and maritime workers, who have their own workers' comp or other system of compensation.
Steps to Follow If You're Injured at Work
- Your first priority should be getting the medical treatment you need. Whether it's a one-time visit to the emergency room or ongoing treatment with a psychologist for a mental health issue, obtaining appropriate medical care is not only good for your health, it's also good for your workers' comp case. When receiving treatment, be sure to mention to your health care provider that your health issue is work-related so that your medical records accurately reflect the situation. Your medical records can prove to the workers' comp board the source of your injury and the extent of your limitations. If you haven't received any treatment for your medical issue, the workers' comp judge might decide that your injury or illness must not be serious.
- Report your injury to your employer as soon as you can—in writing, if possible. State laws limit the amount of time you have to report a workplace injury or illness. In some states you won't be entitled to your full benefits if you wait more than a few days to report your injury, so don't delay.
- Complete the workers' compensation claim forms. Your employer should provide you the forms you need to file a workers' comp claim. If not, these can be downloaded from your state workers' comp board's website or completed online. Again, states strictly limit the amount of time employees have to file workers' comp claims, so file your claim as soon as you can. Keep a copy of your claim forms for your own records.
- Attend any medical appointments. If there's a dispute about the medical evidence in your case, you might be required to attend a medical evaluation. Be sure to tell the evaluator the source of your injury or illness and describe how it limits you on a day-to-day basis. This medical exam can be crucial to your case, so don't miss it.
- Hire a workers' comp attorney. If your claim is denied, contact an experienced workers' comp attorney to represent you. Workers' comp can be a complex area of law with strict deadlines; trying to navigate it by yourself isn't a wise idea.
What Injuries and Illnesses Are Covered by Workers' Compensation?
Injuries and Illnesses Covered by Workers' Comp
When people think of a workers' comp injury, they often picture a one-time, traumatic injury, like a fall from a ladder. But in many states, workers' comp coverage extends to the following types of injury and illness as well:
- Single, traumatic injuries: injuries resulting from a single incident, such as an accident involving heavy equipment
- Cumulative trauma: injuries resulting from repetitive motion or strain, such as carpal tunnel syndrome, tendonitis, or back pain
- Occupational illness: illnesses or diseases resulting from harmful exposure in the workplace, such as asbestosis or conditions caused by chemical exposure
- Mental health injuries: psychological conditions such as PTSD or major depressive disorder (many states don't allow recovery for these conditions unless they stem from a workplace physical injury), and
- Death: when an employee dies because of a work-related injury or illness.
Finally, depending on your occupation and the rules in your state, you might also be eligible for workers' comp benefits if you get COVID-19 as a result of your job.
Injuries and Illnesses Not Covered by Workers' Comp
Workers' comp coverage generally does not extend to the following types of injuries:
- injuries caused by substance abuse
- purposefully self-inflicted injuries
- injuries caused by a coworker's violent behavior, and
- injuries sustained while committing a serious crime.
How to Apply for Workers' Compensation Benefits
A workers' comp case can be broken down into four steps:
- Report the injury to your employer. As noted above, most states require that you report your injury to your employer promptly (usually between a few days and a month). You could lose your right to file a claim if you fail to do so within the time period set by your state.
- File a claim. Most states also require you or your employer to file a claim with your state workers' comp agency. Many states allow you to file your claim online; check the website of your state's labor department for specific filing instructions.
- Insurance company decision. The insurance company then conducts an investigation to determine whether to approve or deny your claim.
- Appeal a denial. If the insurance company denies your claim, you have the right to appeal.
Appealing a Workers' Comp Decision
Appealing a workers' comp denial can be complicated and time-consuming. It often involves a medical exam and several legal proceedings.
Independent Medical Examination
If your employer's insurance company disagrees with a decision by your treating doctor about your medical treatment, the insurer usually has the right to demand that you be evaluated by a doctor of its choice at an Independent Medical Examination (IME). After the IME, the doctor will prepare a report, which you can dispute if it contains any factual inaccuracies.
Mediation or Settlement Conference
A workers' comp judge will often require you to participate in a settlement conference or mediation. At the mediation, a neutral third party will help you and the insurer attempt to resolve your claim informally.
Workers' Comp Hearing
The workers' comp hearing is your opportunity to make your case to a judge if you are unable to settle your claim. The hearing usually involves arguments by the lawyers, testimony by witnesses (including your own testimony), and presentation of evidence such as medical records, documents showing lost wages, and doctors' reports. The judge will then make a decision. You have the right to appeal the decision if the judge rules against you.
Types of Workers' Compensation Benefits
Workers' comp typically pays for a number of different types of benefits:
- Costs of medical care. Workers' comp will pay for your medical bills, including doctors, hospitals, medication, and special equipment. State laws differ as to whether you or your employer gets to choose your medical provider.
- Temporary disability. Temporary disability benefits are awarded if you are unable to work while receiving medical treatment for your injury or illness. If you can't work at all during this time, you'll typically receive payments equal to two-thirds of your average wages. (For more information, see our FAQs on temporary disability benefits.)
- Permanent disability. Permanent disability benefits are awarded if you don't recover completely from your injury or illness. Based on your doctor's assessment of your condition, you'll receive payments for either permanent partial disability or permanent total disability.
- Vocational rehabilitation. If your injury prevents you from returning to your job, you may be entitled to vocational rehabilitation benefits to help you learn to do another job. These may include expenses associated with retraining, career counseling, or other schooling.
- Death benefits. When employees die as a result of a work-related injury, most states provide death benefits to their spouse, children, and other family members who were financially dependent on the employee. (Read more about death benefits.)
Hiring a Workers' Compensation Attorney
Some workers' comp claims are straightforward, but many are contested, lengthy, and complex. An experienced workers' comp lawyer can walk you through the process, keep track of deadlines, and represent you during your appeal.
Hiring a workers' comp lawyer won't cost you anything out of pocket. In most states, workers' comp attorneys charge a percentage of your benefits if you win your case, and nothing (or only case-related expenses) if you lose.
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