Workers’ Compensation Claims

You’ve been injured on the job. Now what? If you have been injured on the job, you are entitled to workers’ compensation benefits. In this section, we answer common questions about what these workers’ compensation benefits are and about the process of filing claims. We will also answer your questions about how your expenses will be paid and the treatment you will receive.

About Workers’ Compensation

What is a workers’ compensation claim?

If you are injured on the job, or if you contract a disease from your job, the law entitles you to workers’ compensation benefits. Your injury or disease must be a result of your job. For example, if you happen to be at work and have a heart attack that is not caused by your work, you will not be entitled to workers’ compensation benefits.

Your benefits can include compensation for such things as lost wages, medical expenses, permanent disability and vocational rehabilitation. Workers’ compensation benefits do not include compensation for pain and suffering.

How do I get wage loss benefits?

If your doctor has taken you off work because of your on-the-job injury, and you miss three days or more of work, you are entitled to compensation for your lost wages or salary. Time loss because of a doctor or therapist appointment will be included. You will usually receive two-thirds of your gross income for the time you are off work, but there are minimums and maximums allowed by law.

If the insurance company has not denied your claim, you are entitled to time loss benefits. If the insurance company denies your claim, it does not have to pay your time loss unless the denial is overturned in a hearing before the Workers’ Compensation Board.

All time loss benefits stop when you are authorized by your doctor to return to your regular work; or when you have recovered from your injury as much as you can. (This is called being “medically stationary.”)

Do I get compensated for pain and suffering?

There is no compensation for pain or suffering in workers’ compensation claims. Write your legislator!


What if my claim is denied?

The insurance company may deny your claim by asserting that you were not injured at work, or that your injury was caused mainly by a pre-existing condition such as arthritis or another injury.

If your claim is denied, you must request a hearing within 60 days or you will probably lose your right to contest the denial. You can expect it to take at least four months from the date you request a hearing until the hearing date.

You will not need to worry about paying for your attorney. The insurance company will pay your attorney fee if you win, but there will be no attorney fee if you don’t win. Sometimes there are out-of-pocket expenses incurred, such as for reports from doctors or the costs to subpoena witnesses for your hearing, which will be your responsibility, win or lose.

When will my claim be closed?

When your attending physician says you have reached your maximum improvement from your injury, you will be declared “medically stationary” and your claim may be “closed.” Note: An injured worker might be medically stationary even if there is not a full recovery.

In order to close your claim, your attending physician is supposed to examine you and determine whether you have any permanent impairment. From your doctor’s impairment evaluation the insurer will determine whether you are entitled to an award of “permanent disability.”

Permanent disability is an arbitrary and small award that does not reflect how your injury might affect your ability to work and earn a living in the future. If worker A and worker B have the same injury and the same impairment, the amount of their permanent disability will be the same, even if worker A was earning only minimum wage and worker B was making $100,000 a year.

If you feel your award for permanent disability was not properly determined, you may request review by the Workers’ Compensation Board. You may request an examination by an independent doctor (“medical arbiter”) if you think your own doctor might have understated your impairment.

Do I have any rights after my claim is closed?

You will be entitled to palliative medical care, which is defined by law as that care necessary to allow you to continue to work or to monitor medications or prosthetic devices you might be prescribed as a result of your injury. Palliative care does not include pain control.

You may be entitled to vocational assistance if you are left with a permanent disability that prevents you from earning 80% of the income you were earning at the time of your injury.

You will have the right to reopen your claim if, within five years of the date your claim was closed, your condition worsens. This would involve a claim for aggravation and could entitle you to further medical treatment and time loss benefits, and a redetermination of permanent disability.

Can workers’ compensation claims be settled?

Workers’ compensation claims can be settled. Sometimes workers can settle their entire claim for an agreed amount of money. Sometimes there is a partial settlement in which workers retain their right to future medical benefits but give up the rest of their claim rights. All settlements must be approved by the Workers’ Compensation Board.

Expenses and Payment

Will my medical expenses be paid promptly?

The insurance company is required to pay your medical bills if your claim is accepted. Your doctors will work on a payment schedule within the guidelines of the workers’ compensation laws.

If your claim has not been accepted, the insurance company is not required to pay your medical bills. If your claim is denied, but you are contesting the denial, your doctors are not allowed to bill you or send your account to collections until your case is over.

Who pays attorney fees?

Workers’ compensation claims, including attorney fees, are strictly controlled by state law. If a claim is denied, a lawyer can represent the worker on a contingency fee basis that will cost the worker nothing. If the denial is overturned (that is, if the attorney is successful in getting the claim accepted) the employer (or the employer’s insurance company) will pay the attorney fee. If the denial is upheld, there is no attorney fee.

Attorneys are usually anxious to take cases they think they can win. If the worker’s doctor supports the claim, it is likely to be a good case. If the employer’s doctors present a reasonable argument that the worker’s injury is not work-related, it makes the case more risky. If the worker’s doctor is hesitant to go up against the employer’s doctors, the case is likely to fail. It is usually necessary for an attorney to obtain the complete claim file from the employer in order to evaluate the claim and determine whether it should be pursued. This is typically done with no charge to the worker.

Receiving Treatment

Can I get the medical treatment I want?

There are restrictions on the medical benefits in workers’ compensation claims.

If your employer has not enrolled with a managed care organization (MCO), you have the right to see the doctor of your choice. If your employer is enrolled with an MCO, you have the right to see any doctor who is a member of that MCO. If you have an established relationship with a doctor who is not a member of the employer’s MCO, you may be allowed to continue treating with your regular doctor, so long as your doctor agrees to go along with the provisions of the MCO.

The doctor in charge of your treatment is called your “attending physician.” Your attending physician will be in charge of referring you to therapists or specialists, if necessary. You have the right to change your attending physician twice, if you want to. For the most part, chiropractors are not allowed to be attending physicians.

Can my employer’s insurance company require me to be examined by the company’s doctor?

The insurance company has the right to send you to a doctor of its choice. The company will call this an Independent Medical Exam, but we call it an Insurance Medical Exam because it is not an impartial exam. It is not unusual for the insurance company’s doctor to say your injury is not related to your work.