Worker's Compensation FAQ's
Q: What is workers' compensation?
A: Workers' compensation is a state-mandated insurance program that provides benefits to employees who suffer job-related injuries and illnesses. Each state has its own laws and programs for workers' compensation. The federal government also has a separate workers' comp program, mostly for federal employees. For up-to-date information on workers' comp in your state, contact your state's workers' compensation office. (You can find links to the appropriate office in your state on the State Workers' Compensation Officials page of the U.S. Department of Labor's website.) In general, an employee with a work-related illness or injury can get workers' compensation benefits regardless of who was at fault—the employee, the employer, a coworker, a customer, or some other third party.
Q: Are all work-related injuries covered by workers' compensation?
A: Workers' compensation covers most work-related injuries—but not all. Generally, workers' comp doesn't cover injuries that happen because an employee is intoxicated or using illegal drugs. Coverage may also be denied in situations involving:
- self-inflicted injuries (including those caused by a person who starts a fight)
- injuries suffered while a worker was committing a serious crime
- injuries suffered while an employee was not on the job, and
- injuries suffered when an employee's conduct violated company policy.
Q: What is the difference between a personal injury claim and a Workers’ Compensation claim?
A: Fault Needed in a Personal Injury Case: A slip and fall case is a good example of fault in a personal injury case. Simply because you slipped and fell on someone else’s property does not mean that the person who owns the property (or anyone else for that matter) was negligent. Accidents, where no one is at fault, do happen. In order to recover damages for slipping on someone else’s property, you and your lawyer must prove that that other person negligently maintained his/her property -- i.e., that he/she did something wrong. Similarly, if you are in a car accident, you can only recover damages from the other driver if the other driver was at fault.
No Fault Needed in a Workers’ Compensation Case: In a workers’ compensation case, any employee injured on the job is entitled to workers’ compensation benefits, with some very limited exceptions. Workers’ compensation has nothing to do with fault. You do not need to prove that your employer or your co-workers did anything wrong in order for you to receive workers’ compensation benefits. Even if you were negligent, and your negligence caused your injury, you are still entitled to receive workers’ compensation benefits.
Q: If a patient has a workers’ compensation claim open can I bill Medicare for denied line items?
A: Medicare may cover costs for Medicare-covered items and services if the state workers' compensation insurance denies payment. If there is a work-related illness or injury, the patient must tell the employer and file a workers' compensation claim. You or your lawyer also need to call the Medicare Coordination of Benefits department and advise them of the injury. Then after that is done the claims can be billed to Medicare as a secondary payer. However, if someone besides your employer was responsible for your injuries, you may be able to bring a third-party lawsuit and to get compensated for things workers’ compensation doesn’t pay for, like pain and suffering. However, if workers’ compensation paid you for things like medical treatment or lost wages, the law allows them to “take a lien” against the third-party lawsuit to reimburse them for a portion of what they paid you. This may seem confusing, because you brought a lawsuit for things workers’ compensation doesn’t pay for, but under the law, the workers’ compensation carrier has a right to reimbursement even if your entire settlement was allocated to pain and suffering. This means that when you settle your case your lawyer had to consider the cost of reimbursing the compensation carrier in addition to compensating you personally for your injuries.
Q: Can a patient have a workers’ compensation claim open in addition to a secondary attorney lien?
A: When you are hurt on the job, workers’ compensation payers you for any medical expenses or lost wages you may have because of the injury. If there is an attorney, the attorney lien would only cover what is not covered by the insurance company such as pain and suffering or other third party responsibility. For Heath Prime, we will not bill secondary liens for any medical expenses as these are covered by the insurance policy.
Q: If an employee is receiving workers' compensation benefits, but returns to work, does the employee still get to receive workers' compensation benefits?
A: The answer to this question is "maybe." If the return to work enables the employee to receive wages equal to or greater than he or she was earning prior to the injury, then it is likely benefits will be stopped. If, however, the employee is still experiencing a wage loss due to his or her injury, he or she may continue to receive wage loss benefits, although the benefits will most likely be for a lesser amount.
Q: Can an employee recover workers' compensation benefits, no matter what he or she did, because it is a "no-fault" system?
A: No. Although most injuries are covered by workers' compensation, that does not mean that employees have free reign to injure themselves, or act in any way they choose, and then collect benefits. Generally, if an employee sustains injures because of intoxication or illegal drug use, benefits may not be payable.
Q: Does workers' compensation cover just my medical bills?
A: Workers' comp does pay hospital and medical expenses that are necessary to diagnose and treat your injury. But it also provides disability payments while you are unable to work (typically, about two-thirds of your regular salary). Depending on the state and the injury, it may also pay for rehabilitation, retraining, disability, death and other benefits.
Q: Are all employees covered by workers' compensation?
A: No. First, not all employers are required to have workers' compensation coverage. State laws vary, but an employer's responsibility to provide coverage usually depends on how many employees it has, what type of business it is, and what type of work the employees are doing. Second, every state excludes certain types of workers. Although these exclusions vary, they often include farm workers, domestic employees, and seasonal or casual workers.
Q: Will workers' compensation cover me for work-related illness or injuries that are not the result of an accident?
A: Yes, workers' compensation will cover you for work related injuries such as repetitive motion injuries. An example of this is carpel tunnel syndrome suffered by workers who do a lot of typing. Workers may develop a variety of illnesses that are related to their jobs. For example, workers in high stress jobs may develop digestive disorders that are related to the stress they experience on the job, or workers who are exposed to a lot of car exhaust on the job may suffer from carbon monoxide poisoning or breathing problems. It really depends on what the hazards of the job are, and some people may develop illnesses because of them while others do not.