FREQUENTLY ASKED QUESTIONS – WORKERS’ COMPENSATION
Workers’ compensation is a benefits program created by state law that provides medical, rehabilitation, income, death and other benefits to employees and dependents due to injury, illness and death resulting from a compensable work-related claim covered by the law.
Workers’ compensation coverage begins the first day of employment. Employers with three or more employees are required by law to provide coverage.
Any injury, illness or death arising out of and in the course of employment is by definition a compensable work-related claim. This means if employees are injured while performing assigned job duties during assigned work hours, they are covered under the workers’ compensation program. Injuries sustained while engaging in unassigned duties, during lunch and breaks, are not covered. In addition, injuries that occur during an employee’s normal commute to and from work are not covered.
You should IMMEDIATELY report your injury to your employer. Obtain and fill out the paperwork required by your company and forward to the appropriate organization for processing. Be as specific as possible when reporting your injury. If anyone witnessed your accident, inform your employer of such a witness. Prompt notification will enable your company to begin your benefits in a timely manner.
If your injury is such that you are unable to make a report, you will be provided immediate medical assistance and a report will be made for you. Others reporting the injury should also be as specific as possible when reporting the accident and the report should be turned over to the employer as soon as possible.
Yes. Your employer and/or the company responsible for handling workers’ compensation claims generally investigate on-the-job accidents and injuries. Investigations are necessary to determine why and how the injury occurred, and to implement policies and procedures to make the workplace safer.
No. Workers’ compensation does not provide benefits for an injury or accident resulting from an employee’s willful misconduct (i.e., fighting, horseplay, willful act of third party for personal reasons, injuries related to alcohol or drug abuse.)
Yes. These types of injuries would be covered under the workers’ compensation program. However, employees are encouraged to follow company policies and safety rules and my subject themselves to company discipline if these rules are not adhered to.
Many companies have established safety programs to encourage employees to be safety conscious when performing their job duties. These programs usually offer certain awards to employees. Employees do not like to be responsible for causing their work group to miss safety goals. However, failure to report injuries because of safety programs could result in long-term consequences for the employee, as well as out-of-pocket medical expenses.
No. Workers’ compensation is the “exclusive remedy” a worker has against his/her employer for damages resulting from an on-the-job injury.
If your injury was caused by the negligence of a third party other than another person who is also an employee of the company for which you work, you may have the right to sue that party. If you sue and receive a dollar awarded, your employer may have a right to recover some or all of the cost expended in your workers’ compensation claim. This is known as a subrogation lien. The lien would only be recoverable after you had been fully compensated for your loss resulting from your on-the-job injury.
Most workers’ compensation claims can be handled without having to hire an attorney. However, if you feel that an attorney is needed, the Workers’ Compensation Statute limits the attorney’s fees to a maximum of 25% of income benefits received, not to exceed 400 weeks of benefits. Another way many attorneys handle fees would be 25% of the lump sum settlement you receive at the conclusion of your claim. In addition, you may be responsible for paying any expenses associated with the pursuit of your claim. These expenses are normally deducted from any lump sum settlement you receive.
· Failure to report injuries promptly.
· Failure to cooperate with employer and authorized treating physician regarding medical evaluations, treatment, rehabilitation services and claim investigation.
· Refusal to return to suitable employment.
· Working elsewhere while receiving temporary total disability benefits.
· Submittal of fraudulent information.
· Refusal to take a drug test.
· Refusal to submit to a medical examination by the authorized treating physician, at reasonable times.
Yes. For instance, benefits are not payable if you are injured while engaged in willful misconduct or if your injury is due to intoxication from marijuana, alcohol or misuses of controlled substances.
Yes. The Board has an Enforcement Division that investigates allegations of fraud. The Board also has authority to assess civil penalties of up to $10,000 for violations of fraud.
No. The law requires that you select from a list of physicians posted by your company in a prominent location. In addition, the law requires that you are informed of this list and understand its function. One of the following referral methods may be used.
Panel of Physicians – This must contain at least six qualified physicians. The makeup of the panel must include one orthopedic surgeon, a minority physician and four other properly qualified physicians.
Conformed Panel – This must include at least ten qualified physicians.
Workers’ Compensation Managed Care Organization (WC/MCO) – A WC/MCO offers a much larger choice of treating physicians from many disciplines. The WC/MCO must be approved by the State Board of Workers’ Compensation.
If you are dissatisfied with your first selection of physicians, you may make one change to another physician from the posted list. Any further change of physician will require concurrence of your company and/or the workers’ compensation administrator.
Should you choose to go to a doctor not on the approved list, this is considered unauthorized treatment and your employer will not be responsible for the cost associated with this medical care. In addition, most health insurance policies will not pay for the medical treatment associated with an on-the-job injury.
The list of physicians will be printed on a 8.5’ x 14 piece of paper titled “OFFICIAL NOTICE, This business operates under the Georgia Workers’ Compensation Law.” It will contain the name, specialty, address and phone number of the authorized physicians.
In a true emergency situation, you may get temporary medical care from the nearest emergency location available. Once the emergency is over, however, you must continue your care by selecting a doctor from the list of physicians provided by your employer.
Prior to scheduling any major surgical procedures for an on-the-job injury, except in the case of an emergency, your doctor will notify your employer or workers’ compensation provider. Once your employer has been contacted, the appropriate workers’ compensation professional will work with your physician and/or his/her medical staff to ensure that all the necessary arrangements are made.
Your authorized treating physician will arrange for these tests. Feel free to ask your physician what the test is for and why you need it.
Your authorized treating physician will refer you to a physical therapy provider.
No. Your physician’s bills and reasonable medical bills are covered if a physician authorized by your employer treats you. All medical charges are paid according to the Georgia State Fee Schedule. If your medical provider charges above the Fee Schedule, the charges will be reduced to the Fee Schedule and that amount will be paid. YOU ARE NOT RESPONSIBLE FOR CHARGES ABOVE THE FEE SCHEDULE; however, if you are billed for those costs, contact your employer or workers’ compensation provider to assist in getting the charges corrected.
Prescription drugs are covered under workers’ compensation. Check with your employer or workers’ compensation administrator to see if they have any special procedures in place for obtaining prescription drugs. If no special arrangements have been made, you may have to pay for the prescription and submit the bill to your employer for reimbursement.
The Workers’ Compensation Statute provides for reimbursement of certain reasonable personal expenses incurred to obtain medical treatment. This includes such things as mileage, meals, lodging and other expenses, in limited instances, that are deemed necessary and appropriate in order to ensure you receive quality medical care. You should check with your workers’ compensation professionals before incurring expenses.
Approved expenses will be reimbursed within 30 days of submission as required by the Workers’ Compensation Statute. However, most carriers process reimbursements in less time. If reimbursements are not paid within thirty (30) days of receipt of documentation requesting reimbursement, penalties will be added, in addition to the reimbursement amount.
You are entitled to receive weekly temporary total disability benefits if you miss more than seven days from work. Only if you are out more than 21 consecutive days due to your injury will you be paid for the first seven days. Your first check should be mailed to you within 21 days after the first day of disability. You will receive two-thirds of your average weekly wage, but not more than the maximum rate provided by the Workers’ Compensation act at the time of your injury. Your authorized treating physician must verify your disability and absence from work.
You would be eligible to receive temporary total disability benefits if you are unable to work due to your on-the-job injury. You should consult with your employer regarding possible vocational rehabilitation opportunities.
If your authorized treating physician determines you have suffered a permanent disability, you would be entitled to receive temporary total disability benefits for as long as you remain disabled. If you are not able to work, you would begin receiving a weekly income benefit based on the permanent disability rating given to you by your authorized treating physician. (See next question – PERMANENT PARTIAL DISABILITY). The benefit would be paid to you regardless of your wage rate or total income.
The Workers’ Compensation Statute provides four basic income benefits. The maximum amount of weekly workers’ compensation benefits an employee can receive from an on-the-job injury, illness or death depends on the workers’ compensation rate at the time of the injury and the employee’s average weekly wage.
Temporary Total Disability Benefits – This benefit is payable to an employee who is injured on the job and unable to work as determined by the authorized treating physician. The amount is two-thirds of the employee’s average weekly wage at the time of the injury, not to exceed the maximum amount allowed under the law. For non-catastrophic injuries, there is a limit of 400 weeks of benefits from the date of injury if the injury occurred on or after July 1, 1992. For catastrophic claims, benefits are unlimited.
Temporary Partial Disability Benefits – This benefit is payable to an employee when he/she returns to work in a job paying less as a result of the on-the-job accident. These benefits are payable for up to 350 weeks from the date of injury. This lost wage amount is two-thirds of the difference between the employee’s average weekly wage before and after the injury. The maximum amount payable cannot exceed the maximum allowed under the law.
Permanent Partial Disability Benefits – This benefit is payable to the employee for a permanent disability resulting from an on-the-job injury. It is payable based upon a percentage given by your authorized treating physician in accordance with current AMA Guidelines. The percentage is calculated by a formula that contains the number of weeks assigned by the State Board (x) the percentage rating (x) the temporary total disability rate. Not all injuries result in ratings assigned by a physician.
Death Benefits – This benefit is payable to eligible dependents (i.e., dependent spouse, minor children) of an employee whose on-the-job injuries result in death. This benefit is payable at the rate of two-thirds of the deceased employee’s average weekly wage at the time of the accident not to exceed the maximum allowed under the law for all eligible dependents. Funeral expenses are payable up to the maximum allowed under the law at the time of the injury.
Benefits cannot be combined. Only one type of benefit is payable at a time.
Your employer will try to place you in a job that meets the limitations placed on you by your physician. However, if a light-duty job is not available and you remain out of work in a light-duty status for 52 consecutive weeks or, if periods of disability are interrupted, a maximum of 78 total calendar weeks, your income benefits will be reduced automatically by law from temporary total disability benefits to the maximum eligible temporary partial disability benefit.
If you are given a light-duty release and a light-duty job is available, your employer will expect you to return to work. The Workers’ Compensation Statute provides for a 15-working day “grace period.” This allows an employee to attempt to perform a light-duty job without fear of losing benefits if they are unable to perform the job duties.
Yes. If your disease meets certain tests imposed by law, you can be compensated. There must be a causal relationship between your employment and the disease. It cannot be a disease that is an ordinary disease of life to which others are exposed.
The Workers’ Compensation Act limits the extent to which an aggravation of a pre-existing condition or injury is compensable. An aggravation of an on-the-job injury is compensable while the aggravation is the cause of the disability. Once the aggravation resolves and you return to the pre-injury condition, the claim will no longer be compensable.
Yes. Repetitive motion injuries are compensable if they arise out of and in the course of employment.
Catastrophic injuries are extremely severe injuries, (i.e., loss of limbs, severe burns, etc.). Your employer is required to appoint a rehabilitation supplier who has expertise in handling catastrophic claims. This person would assist you in managing your medical care as well as any other assistance you might need in the recovery period following the accident. You will be entitled to temporary total disability benefits for as long as you remain unable to work. Once you have returned to work, the temporary total disability benefits will cease. If you are placed in a lower paying job, you will begin receiving temporary partial disability benefits. After those benefits have been paid, you will begin receiving permanent partial disability benefits.
Heart attacks and strokes are not considered injuries under workers’ compensation unless it is shown by a preponderance of competent and credible evidence, which shall include medical evidence, that the condition was attributable to the performance of the usual work of employment.
If your claim is denied, you will be notified of the reason for the denial. You have the right to request a hearing from the State Board of Workers’ Compensation if you disagree with the denial of your claim. A claim with the State Board of Workers’ Compensation is outlined on the back of the Workers’ Compensation form titled “Employer’s First Report of Injury” (WC-1).
After properly reporting the injury, you have one year from the date of the injury to file a claim. If you received remedial treatment from your employer for the injury, you have one year from the date of treatment to file a claim for workers’ compensation benefits. If you received weekly income benefits as a result of the on-the-job injury, you have two years from the date of your last payment of weekly income benefits to file a claim.
In the case of an occupational disease claim, you have one year from the date you became aware of your disease or, in the exercise of reasonable diligence, should have known of the relationship between your disability and its relationship to your employment. No claim for an occupational disease may be filed after seven years from the last date you were exposed to the employment hazards related to your disease. However, for the diseases asbestosis or mesothelioma related to exposure to asbestos, you have one year from the date of first disablement after diagnosis to file a claim.
Yes. You can go back to your authorized treating physician and receive treatment in accordance with the established guidelines set by the State Board of Workers’ Compensation as outlined above.
When appropriate benefits have been paid, or once a settlement agreement is reached by all parties and approved by the State Board of Workers’ Compensation and a monetary amount is paid to you or your dependents, your claim is closed. Note that not all claims are closed. Some claims, due to the nature of the injury, remain open until the statute of limitations runs, or until the injured’s death, whichever occurs first.
Information provided by Georgia State Board of Workers’ Compensation.
Contact: Kathleen S. Grantham, Esq.
The information obtained from this site is not, nor is it intended to be, legal advice. Always consult with an attorney for advice pertaining to your individualized case.
Grantham Law Office
403½ S. Pleasant Hill Rd.
Warner Robins, Georgia 31088