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How Does Workers’ Compensation Work?

Workers’ compensation is an insurance program that provides benefits to workers who are injured while performing their job duties. If a worker becomes injured while on the job, he or she is entitled to financial compensation to cover medical costs during their recovery period or even after, if they become permanently disabled from work.

Need to Know:

  • Workers’ compensation is an insurance program that provides benefits to workers who are injured while performing their job duties.
  • It is a no-fault program, meaning that workers are eligible for benefits even if they are found to be at fault for the accident.
  • Medical treatment, lost wages, disability benefits, and survivor benefits can be awarded via workers’ compensation if they are injured on the job.

Workers’ compensation programs benefit the employer as well; if an employer has workers’ compensation insurance, they will not have to pay any expenses out of pocket if an employee is injured on the job.

In This Article:

The specifics of workers’ compensation programs vary by state, but in most states, the general process for filing a claim is the same. No matter where you live, if you were injured on the job, you should understand how workers’ compensation works so you can get the benefits you deserve.

What is Workers’ Compensation?

To understand how workers’ compensation works, there are a few key things to know, such as who qualifies for workers’ compensation benefits and what injuries are covered.

Who is Eligible for Benefits?

To obtain benefits from a workers’ compensation program, a worker has to be eligible. Fortunately, workers’ compensation programs are generally designed to protect injured workers, and you do not need to meet many requirements to qualify.

In order to be considered for workers’ compensation benefits, three things must be true:

  1. The worker was injured while performing job-related tasks.
  2. The worker is an official employee and not an independent contractor.
  3. The injured worker’s employer maintains workers’ compensation insurance.

Essentially, this means that the majority of workers who are injured while carrying out job duties are eligible for monetary compensation, because most employers in almost every state are required to have workers’ compensation insurance. (In many states, your employer could be violating the law if they do not have workers’ compensation insurance.) There are a few exceptions to this eligibility rule: if you are a federal employee, a longshore or harbor worker, a coal mine worker, or a Department of Energy employee, you must obtain compensation through one of these federal programs.

You should know that if you were injured at work in New York State, you may apply for New York State workers’ compensation benefits even if you are a resident of a different state. Your immigration status is irrelevant. Undocumented workers who get injured on the job have the same Workers’ Compensation rights as those workers who are documented.

Finally, it is important to note that workers’ compensation is a no-fault program. In other words, a worker injured on the job is eligible for benefits, even if he is found to be liable for the accident.

For example, if a worker operated a piece of equipment even though he was not trained to do so and was injured as a result, he could still obtain benefits through workers’ compensation even though operating equipment without proper training might be considered careless behavior. You will qualify for benefits even if you fell off a scaffold that you assembled improperly or you injured your head in a fall where you failed to wear personal protective equipment that was provided to you by your employer.

What Injuries Are Covered?

Every state has different rules that dictate what injuries are covered under workers’ compensation. However, generally most work-related physical injuries are covered. Exceptions typically include injuries that occurred because of intoxication or drug use, injuries that were self-inflicted, injuries that occurred while the employee was committing a crime or was in violation of work policies, or injuries that occurred while the employee was not on the clock (commuting to or from work, for example).

Aside from injuries that result directly from accidents, work-related illnesses or long-term injuries can also be covered under workers’ compensation. A common example is the sickness that results from exposure to asbestos, but issues such as heart disease or chronic back pain could also be covered under workers’ compensation if the worker can provide strong evidence that there is a connection between the injury or illness and his work.

An experienced and diligent Workers’ Compensation attorney may also establish consequential injuries in your case.

Very often, an injured worker may develop consequential lumbar spine or hip injury if they sustain a serious lower extremity injury leading to antalgic gait. For example, if a construction worker falls off a ladder and suffers a calcaneus fracture requiring surgical intervention. A result could be that the victim is not able to walk without assistance for a prolonged time, and they may develop an antalgic gait. An abnormal pattern of walking secondary to pain may affect other body parts, especially the lumbar spine and hip. You may be able to claim additional consequential injuries in your case even though those body parts were not directly injured in the work-related accident.

How Does Filing a Workers’ Compensation Claim Work?

After a worker becomes injured on the job, the general process for filing a workers’ compensation claim to obtain benefits is the following:

  1. The injured employee should seek medical treatment as soon as possible. If the injuries do not require emergency treatment, the employee should check with their supervisor to determine if they must see a specific doctor that is covered by the workers’ compensation insurance policy.
  2. The worker should report the injury to his employer as soon as possible. This is important because in order for the worker to receive sufficient compensation, there needs to be a record of his injuries from the beginning. Time limits for reporting the injury vary by state. In New York, for example, the worker has 30 days to notify his employer of his injuries, or he may lose the right to receive benefits. Written notification is preferred so there is a tangible record on file, even if the employee has already verbally told their employer about the accident.
  3. The employee must file an official claim form. This form varies by state, but it typically asks for details about the accident, the injuries sustained, and what kind of medical treatment will be required. Generally, employees can obtain the necessary forms from their employer.
  4. The employer submits the claim to the insurance carrier. Medical documentation may also be submitted to the insurance carrier by the worker’s doctor.
  5. The insurance carrier approves or denies the claim. Again, this process varies by state, but in New York, within 14 days (2 weeks) of the employer submitting the claim, the insurance company must provide the worker with a written statement of his rights as an injured worker. Then, within 18 days (about 2 and a half weeks) of receiving the claim, the insurance company will either accept it and begin paying the worker benefits, or they will deny it and explain why. If that is the case, employees have the right to appeal their case, and often will hire legal representation to help with the appeal.
  6. The employee receives benefits until they are able to return to work. Typically, employees receive benefits every two weeks. Once the employee is cleared by their doctor to return to work at full capacity, they should notify their employer, who will let the insurance carrier know that the payments can be stopped. Sometimes, however, the worker is unable to return to work at the same capacity that they were before the accident; in this case, they may have to take on “light duty” work or may even need to find another job entirely. See below for more information on the types of benefits workers can receive, both during and after their recovery. You still may receive a lump sum award in case you injured your upper or lower extremities and you returned to work on full duty. This award is called a schedule loss of use award. The Workers’ Compensation Board may award you an award based on the permanent damage reported by your treating physician and an independent medical examiner hired by the insurance company.

The process for filing a claim and obtaining workers’ compensation benefits involves collaboration from multiple parties, including the employee, the medical provider, the employer, the insurance carrier, and often the state’s workers’ compensation board as well. Sometimes, the employee will also have a lawyer to help them through the process, as it can be exhausting to navigate while also trying to recover from injuries.

If you have been injured in a work accident and would like to discuss your case with a workers’ compensation attorney, call 212-736-5300 today. If English is not your first language and you require an interpreter to assist you at a Workers’ Compensation hearing, the Judge will provide one for you upon your request. 

What Kind of Benefits Can Workers Receive?

Generally, workers who have been injured on the job can receive compensation for:

  • Initial medical treatment and ongoing care throughout their lifetime
  • Wages lost while they were unable to work
  • Disability benefits if they are unable to return to work either temporarily or permanently
  • Survivor benefits and coverage of funeral expenses for the family if the worker dies from their job-related injuries

There are different disability classifications that determine the amount of compensation a worker can receive. These classifications are based on the severity of the worker’s injuries and their ability to return to work.

Typically, workers stop receiving benefits once they are considered to be fully recovered and can return to work without any restrictions. However, if they are unable to return to work or if they must return to work at a reduced capacity because of their injuries, they may be able to continue receiving disability benefits through the workers’ compensation program. These classifications include:

Temporary Total Disability

This category typically applies when the worker has just been injured and is in the initial recovery period. He is unable to work at all due to his injuries, but it is expected that will only be the case temporarily. The worker will likely receive full lost wage benefits. The weekly benefit cannot exceed the maximum benefit amount. The maximum benefit amount adjusts every July 1.

It is based on the New York State Average Weekly Wage for the previous calendar year, as reported by the Commissioner of Labor to the Superintendent of Insurance on March 31 of each year. If you were injured between July 1, 2022, and June 30, 2023, your weekly maximum benefit will amount to $1,125.46. If your work accident occurred between July 1, 2023, and June 30, 2024, your weekly maximum benefit will be $1,145.43.

Temporary Partial Disability

These benefits apply when the worker has been in recovery for some time, and it is determined that his injuries will allow him to return to work, but not at full capacity, which means he will also not earn his former full amount of wages. He likely will need to be on “light duty” and will be restricted in what he can do. In this case, the worker can continue to receive benefits to supplement his lesser paycheck, until the worker is determined to have recovered completely and can return to work at his former full capacity.

Permanent Partial Disability

This category applies when the worker has reached “maximum medical improvement,” or MMI. At this point, it is determined that the worker has recovered as fully as possible, but he has sustained a permanent injury that will reduce his earning capacity because of his work accident. Such an injury might include loss of vision or a permanent loss of function in the legs or arms.

Permanent Total Disability

A worker receives this category of benefits when it is determined that his injuries have completely disabled him from returning to work. He can no longer earn wages in any capacity.

The exact amount of compensation a worker can receive is determined on a case-by-case basis. However, each state sets a maximum for the amount of benefits a worker can receive weekly. This amount is adjusted every year and is based on the state’s average weekly wage. For example, in New York, the maximum amount of benefits a worker could receive weekly for the 2020 calendar year was $966.78.

The Difference Between Workers’ Compensation and Personal Injury Benefits

As mentioned earlier, workers’ compensation is a no-fault system, meaning that a worker is entitled to benefits even if negligence played a role in causing the accident. If a worker’s carelessness contributed to his accident, his benefits will not be reduced, nor will they be increased if it is found that another party’s negligence contributed to causing the accident.

Because of the no-fault system, workers are barred from bringing personal injury claims against their employers.

However, it is still possible to file a third-party claim against another negligent party, such as a contractor, construction site owner, or equipment manufacturer. For example, a construction worker suffers head injuries after a crane malfunctions and drops an object onto him. The injured worker can obtain workers’ compensation benefits since he has been hurt on the job. In this case, it is possible he could also file a third-party personal injury lawsuit against the crane manufacturer, since the crane’s malfunction caused his injury.

Additionally, he might even be able to file a third-party claim against the construction site’s contractor, as it is partially a contractor’s responsibility to ensure a work site is safe. It is in your best interest to speak to a personal injury lawyer if you are already obtaining workers’ compensation benefits and believe you may also have a personal injury case.

Work Accident Lawyers Recovering Compensation for Injured Employees

Becoming injured can be a scary, life-altering event, but understanding how workers’ compensation programs work is the first step towards obtaining financial compensation for your injuries. If you believe that another party’s negligence contributed to causing your accident, you may be able to file a third-party personal injury claim in addition to your workers’ compensation benefits.

If you would like to discuss your legal options, call 212-736-5300 to speak to a Block O’Toole & Murphy attorney today. Notable results we have obtained for injured workers include:

  • $53,500,000 jury verdict for a construction worker who became permanently paralyzed from the waist down after falling 10 to 12 feet at a job site
  • $15,000,000 settlement in a wrongful death case for the surviving wife and children of an HVAC technician who was tragically killed on the job by a falling object
  • $12,000,000 settlement for a union tunnel worker who suffered multiple severe injuries, including a total femur replacement, after he fell 40 feet in a ventilation shaft
  • $11,500,000 settlement for a union construction worker who suffered Complex Regional Pain Syndrome in his hand and wrist after he was cut while using a defective saw
  • $11,000,000 settlement for a masonry foreman who fell three stories through an unsecured temporary hole cover and suffered multiple injuries, including pelvic fractures that required surgery
  • $10,875,000 jury verdict for a union worker who was working on a rooftop construction site when he slipped and fell onto a vertical piece of rebar, causing severe internal injuries
  • $10,500,000 settlement in a wrongful death case for the surviving family of a union worker who suffered fatal injuries after being struck in the neck by a defective saw
  • $7,400,000 settlement for a union sheet metal worker who fell off a narrow steel beam, leading to the need for multiple spinal surgeries
  • $7,300,000 settlement for a construction worker who had to have his right arm amputated after a 10,000-pound steel beam collapsed onto him
  • $7,000,000 settlement for a carpenter who sustained multiple facial fractures and neck pain after he was struck in the face by a five-pound falling object
  • $7,000,000 settlement for a worker who fell 30 feet down an elevator shaft, which resulted in serious crush injuries that required a total of nine surgeries

Dial 212-736-5300 or fill out our online contact form to schedule a FREE, no-obligation consultation with a work accident attorney today. We serve New York and New Jersey.

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