What's covered under workers compensation?
Workers' compensation is a term for both federal and state provisions that govern injuries arising out of employment, and provide for guaranteed, but limited, payments for those injuries. Under a system of workers' compensation, injured employees need not bring a legal action against their employer and need not prove negligence or other theories of liability; the system, however, then bars covered employees from recovering for their injuries under other compensation schemes such as common law torts. While the federal government administers a workers' comp program for federal and certain other types of employees, each state has its own laws and programs for workers' compensation. In general, an employee with a work-related illness or injury can get workers' compensation benefits regardless of who was at fault. In exchange for these guaranteed benefits, employees usually do not have the right to sue the employer in court for damages for those injuries.
An employee who is injured on the job must follow three basic steps. First, you must obtain medical treatment as soon as possible from a health care provider authorized for workers compensation injuries, except in an emergency situation. Second, you must notify your supervisor about the injury and how it occurred, as soon as possible. Failure to timely notify your supervisor could bar you from receiving benefits. Third, you must complete a claim for workers' compensation. If the claim is not timely filed, you may lose your right to benefits.
The workers' compensation system provides, (1) replacement income when employees are off work, (2) payments for medical expenses, including doctors' visits, surgeries, and prescription drugs, and (3) vocational rehabilitation benefits, including on-the-job training, education, or job placement assistance. An employee who is temporarily unable to work will usually receive temporary disability payments of two-thirds of the employee's average wage, up to a fixed ceiling. An employee who becomes permanently unable to do the work he or she was doing prior to the injury, or unable to work at all, may be eligible for long-term or lump-sum benefits for permanent disability. The workers' compensation system also pays death benefits to surviving dependents of workers who are fatally injured in a work-related incident.
Injuries or illnesses are typically covered only when they "arise out of and in the course of employment." There needs to be a connection between the accident that caused the injury or illness and the scope of your employment duties. Examples of compensable injuries are those caused by lifting heavy equipment, slipping on a wet or oily surface, defective machinery, or fires or explosions. Many state workers' compensation programs preclude coverage for injuries which occur while you are not acting within the scope of your employment, such as while you are playing football with friends on your day off. Generally, any injury occurring at work which is due to a traumatic incident, such as falling from a ladder, or that is due to cumulative factors, like injuries caused by repetitive motions, would be considered as arising out of employment. Illnesses created by the work environment, like medical conditions caused by exposure to chemicals, are also compensable. In general, any injury or illness that requires the worker to see a doctor or that results in disability or death qualifies for workers' compensation benefits. A doctor must be able to verify that there is objective medical evidence showing that an injury or disease exists and that work exposure was the major cause. Generally, however, those injuries suffered while going to or coming from work are not considered to be arising out of and in the course of employment, even if the employer provides transportation, unless the employee is engaged in a special errand or mission for the employer.
Employers, and not the employees themselves, will often be held liable for the conduct of their employees. This is true even if the employer had no intention to cause harm and played no physical role in the harm. First, employers are seen as directing the behavior of their employees and accordingly, must share in the good as well as the bad results of that behavior. By the same token that an employer is legally entitled to the rewards of an employee's labor (profit), an employer also has the legal liability if that same behavior results in harm. Second, when someone is injured or harmed and needs to be compensated, who is the most likely to pay: the employee or the employer? Fair or not, the legal system is interested in making the victim whole, and assigning liability to the employer rather than the employee has the best chance of meeting that goal.
In most states, employers are required to purchase insurance for their employees from a workers' compensation insurance carrier. In some states, larger employers who are clearly solvent are allowed to self-insure, or act as their own insurance companies, while smaller companies are not required to carry workers' compensation insurance at all. When a worker is injured, his or her claim is filed with the insurance company, or self-insuring employer, who pays medical and disability benefits according to a state-approved formula. Unless they fall within limited, exempt categories, employers without workers' compensation insurance are subject to fines, criminal prosecution, and civil liability.
A worker may be disabled only partially or totally, and, temporarily or permanently. The laws treat each of these conditions differently. Partially, temporarily disabled: This condition will generally allow the injured worker to receive benefits based on a schedule that bases payments on a percentage of maximum benefits. Generally, a worker will receive these benefits until released to their former job or until a determination that the injury is more permanent. Partially, permanently disabled: This condition generally allows a worker to receive a percentage of the full benefit on a monthly basis for the remainder of his or her life, unless the condition improves. When the partial disability is a certain percentage below 50 percent, the worker is offered a lump sum payment in most states. Generally, lump sum payments are final and the worker cannot later claim a larger amount. Totally, temporarily disabled: Many injuries cause total disability for a temporary period. Workers with this condition are typically paid their full benefit amount until they are able to return to work or their condition improves. Totally, permanently disabled: These workers generally receive the state's full benefit amount on a monthly basis for the rest of their lives.
State workers' compensation laws provide exceptions to the rule that workers injured on the job are entitled to compensation. Each state is different, but the exceptions may include: (1) Denied compensation in those cases in which the employee's injury results from his or her attempted suicide or homicide. (2) Denial of compensation to employees injured during the commission of crimes while on the job. (3) Disallowance of compensation for injuries at work that are the result of employees who are injured while engaged in unauthorized horseplay on the job, for those leaving the employers' premises, or for other deviations from employment without the employers' express approval for deviation. (4) Reduction of benefits in some states if the injury was caused by an incident in which the employee failed or refused to use safety appliances provided by the employer.
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