For more information, please see Frequently
Asked Questions – Workers’ Compensation
WORKERS’ COMPENSATON
OVERVIEW
Established in 1920 by the Georgia legislature, the State Board of Workers' Compensation serves over a quarter of a million employers in Georgia and over 3.8 million workers. The State Board is funded by assessments from insurance companies and self-insured employers. An employee that is injured on the job and is covered by the law may be eligible for replacement of a portion of lost wages, medical payments, vocational rehabilitation services and other benefits.
Prior to
the passage of the Workers' Compensation Act, an employee who was injured on
the job could not expect benefits from the employer. Men, women, and children
were often subjected to harsh and oppressive working conditions with little or
no recourse for work-related injuries. Courts often denied recovery to
employees by holding that employees assumed risks in taking the job, were
negligent, or were barred from recovery by the negligence of a fellow employee.
Filing a suit in court was also unsatisfactory because trials were expensive
and often lengthy. This posed a problem to an employee who needed money
immediately to pay for medical expenses and replace lost wages. A successful
suit could also force a small company out of business.
Today, the
workers' compensation law provides for specific benefits to be paid to
employees for injuries arising out of and in the course of employment, without
regard to negligence or fault, and at the same time,
provides the employer with limited liability. In Georgia, employers obtain
worker's compensation coverage through private insurers or programs of
self-insurance. The rights granted an employee under the law preclude any other
legal remedies against an employer by an employee due to a work-related injury.
The law is
applicable to all employers, including public corporations and nonprofit
organizations that have at least three full-time or part-time employees.
There are
several categories of workers who are specifically exempted from the workers'
compensation law: federal government employees, railroad employees, farmers and
farm laborers, and domestic servants, to name a few.
If facts
concerning a claim are contested or liability is questioned, either the
employee or the employer/insurer may request a hearing before an Administrative
Law Judge to resolve the issues. If either party is dissatisfied with the decision,
a party may request a review by the Appellate Division. Further appeals may be
taken through the court system; however, the courts can review only disputed
questions of law, while Administrative Law Judges and the Appellate Division
determine both factual and legal issues.
Although
the Subsequent Injury Trust Fund is a separate state agency, the Board and the
Fund work closely together. The Fund reimburses the employer/insurer for a
portion of workers' compensation benefits paid in cases where a preexisting
permanent impairment combines with a subsequent injury to produce a greater
disability than would have resulted from the subsequent injury alone. The
workers' compensation program is entirely funded by assessments from insurance
companies and self-insured employers.
EMPLOYEE’S RIGHTS
1.
If you are injured on the job, you may receive
medical rehabilitation and income benefits. These benefits are provided to help
you return to work. Your dependents may
also receive benefits if you die as a result of a job-related injury.
2.
Your employer is required to post a list of at least
six doctors or the names of the certified WC/MCO that provides medical care,
unless the Board has granted an exception. You may choose a doctor from the
list and make one change to another doctor on the list without the permission
of your employer. However, in an emergency, you may get temporary medical care
from any doctor until the emergency is over, then you must get treatment from a
doctor on the posted list.
3.
Your authorized doctor bills, hospital bills,
rehabilitation in some cases, physical therapy, prescriptions, and necessary
travel expenses, (including mileage reimbursement to medical providers)
will be paid if injury was caused by an accident on the job.
4.
You are entitled to weekly income benefits if you
have more than seven days of lost time due to an injury. Your first check
should be mailed to you within 21 days after the first day of missed work. If
you are out more than 21 consecutive days due to your injury, you will be paid
for the first week.
5.
Accidents are classified as being either catastrophic
or non-catastrophic. Catastrophic injuries are those involving amputations,
severe paralysis, severe head injuries, severe burns, blindness, or of a nature
and severity that prevents the employee from being able to perform his or her
work and any work available in substantial numbers within the national economy (for
which you are qualified). In catastrophic cases, you are entitled to
receive two-thirds of your average weekly wage but not more than $500 (2008)
per week for a job-related injury for as long as you are unable to return to
work. You are also entitled to receive medical and vocational rehabilitation
benefits to help in recovering from your injury. If you need help in this area
call the State Board of Workers’ Compensation at (404) 656-3818 or our office
at (478) 923-0300 for help and more information concerning catastrophic claims.
6.
In all other cases (non-catastrophic), you are
entitled to receive two-thirds of your average weekly wage but not more than
$500 (2008) per week for a job-related injury. You will receive these
weekly benefits as long as you are totally disabled, but no longer than 400
weeks. If you are not working and it is determined that you have been capable
of performing work with restrictions for 52 consecutive weeks or 78 aggregate
weeks, your weekly benefits will be reduced to two-thirds of your average
weekly wage but no more than $334 per week, not to exceed 350 weeks.
7.
When you are able to return to work, but can only get
a lower paying job as a result of your injury, you are entitled to a weekly
benefit of not more than $334 per week for no longer than 350 weeks.
8.
Your dependent(s), in the event you die as a result
of an on-the-job accident, will receive burial expenses up to $7,500 and
two-thirds your average weekly wage, but not more than $500 (2008) per
week. A widowed spouse with no children will be paid a maximum of $150,000.
Benefits continue until he/she remarries or openly cohabits with a person of
the opposite sex. (This is assuming that every injured employee is
heterosexual.)
9.
If you do not receive benefits when due, the
insurance carrier/employer must pay a penalty, which will be added to your
payments.
Information provided by Georgia
State Board of Workers’ Compensation.
MEDICAL BENEFITS
While on a
national basis, Georgia’s injured workers receive a small amount in income
benefits, as compared with other states; Georgia’s medical benefits are ranked
some of the best. These medical benefits are not provided through co-insurance
and you’re not required to pay any deductibles.
If your
claim is filed timely (within one year from the date of accident) your medical
benefits in reference to these work-related injuries can extend the rest of
your lifetime. Medical benefits for your
work-related injuries will continue regardless of whether you’re working for
the same employer, whether you’ve changed jobs and now work for a different
employer, or whether you’re working at all.
Although, subsequent injuries while working for a new employer may
become the responsibility of the new employer, constituting an aggravation of a
pre-existing condition, if the new employer were aware of the pre-existing
condition prior to hiring you.
Although
Georgia’s workers’ compensation medical benefits are excellent in theory and on
paper, it’s sometimes difficult to get the treatment you need from medical
providers because, although not required by the State Board of Workers’
Compensation, they will insist that they receive preauthorization for the
treatment from the employer/insurer prior to issuing the treatment. This unfortunate reality can sometimes delay
treatment and result in further medical problems.
Some
important elements of medical benefits include:
1.
Causation – The need for the medical
treatment must be directly related to the on-the-job compensable injury. The employer/insurer may even be responsible
for diagnostic tests performed to determine whether or not a condition was
caused by the injury. The
employer/insurer may even be responsible for these charges when the tests
results determine that the condition is not related to the on-the-job
compensable injury.
2.
Authorized Care – An authorized provider
must render the care you receive. Generally, you receive treatment from your
authorized treating physician, who in turn can refer you to other providers for
treatment, but these providers are not allowed to refer you further to
additional providers or for additional diagnostic testing. All treatment referrals and diagnostic
testing referrals must go through your authorized treating physician, unless
the treatment you receive is emergency treatment, as provided in the statute.
3.
Effect a Cure,
Give Relief, or Restore the Employee to Suitable Employment – This
element is one of the main things that an administrative law judge will
consider when medical issues arise.
O.C.G.A. 34-9-200(a) states that the medical treatment the injured
employee receives “shall be reasonably required and appear likely to effect a cure, give relief, or restore the employee to
suitable employment.” The section was
designed to bring about, hopefully for the better, a change in the employee’s
medical condition. If a medical issue is
put before the Board, it is the injured employee’s burden to prove that the
medical treatment provided or for which they are seeking has or will effect a cure, give relief, or restore him/her to suitable
employment.
4.
Medical Charges Must be Usual, Customary and
Reasonable – The State Board reserves the right to approve all
charges, both as to the amount and necessity.
Administrative law judges make decisions on a regular basis concerning
whether or not an injured employee’s medical treatment is necessary or
not. They can even rule that the
treatment is not necessary when the injured employee has some evidence showing
that the treatment is necessary. This is
where the preponderance of evidence takes over and your claim get more
complicated. Should you confront issues
such as this, please consult with a reputable workers’ compensation attorney
concerning your rights.
An injured
worker who files his/her claim within one year of the date of injury is
entitled to lifetime treatment for the work injury. If income benefits have been paid in the
claim, there is no reason to file a claim, the claim was started when the
injured employee started receiving income benefits and he/she has a lifetime
right to medical treatment. Even if an injured employee started receiving
income benefits and then retained an attorney to help with his/her claim, the
attorney would probably go ahead and file a Notice of Claim in reference to the
injury to assure that the injured employee’s rights to medical treatment are
preserved.
EMPLOYEE’S RESPONSIBILITIES
1.
You should follow written rules of safety and other
reasonable policies and procedures of the employer.
2.
You must report any accident immediately, but not
later than 30 days after the accident, to your employer, your employer’s
representative, your foreman or immediate supervisor. Failure to do so may
result in the loss of the benefits.
3.
Any employee has a continuing obligation to cooperate
with medical providers in the course of their treatment for work related
injuries. You must accept reasonable medical treatment and rehabilitation
services when ordered by the State Board of Workers’ Compensation or the Board
may suspend your benefits.
4.
No compensation shall be allowed for an injury or death
due to the employee’s willful misconduct.
5.
You must notify the insurance carrier/employer of
your address when you move to a new location. You should notify the insurance
carrier/employer when you are able to return to full-time or part-time work and
report the amount of your weekly earnings because you may be entitled to some
income benefits even though you have returned to work.
6.
A dependent spouse of a deceased employee shall
notify the insurance carrier/employer upon change of address or remarriage.
7.
You must attempt a job approved by the authorized
treating physician even if the pay is lower than the job you had when you were
injured. If you do not attempt the job, your benefits may be suspended.
8.
If you believe you are due benefits and your
insurance carrier/employer denies these benefits, you must file a claim within
one year after the date of last authorized medical treatment or within two
years of your last payment of weekly benefits or you will lose your right to
these benefits.
9.
If your dependent(s) do not receive allowable benefit
payments, the dependent(s) must file a claim with the State Board of Workers’
Compensation within one year after your death or lose the right to these
benefits.
10.
Any request for reimbursement to you for mileage or
other expenses related to medical care must be submitted to the insurance
carrier/employer within one year of the date the expense was incurred.
11.
If an employee unjustifiably refuses to submit to a
drug test following an on-the-job injury, there shall be a presumption that the
accident and injury were caused by alcohol or drugs. If the presumption is not
overcome by other evidence, any claim for workers’ compensation benefits would
be denied.
12.
You shall be guilty of a misdemeanor and upon
conviction shall be punished by a fine of not more than $10,000 or
imprisonment, up to 12 months, or both, for making false or misleading
statements when claiming benefits. Also, any false statements or false evidence
given under oath during the course of any administrative or appellate division
hearing is perjury.
Information
provided by Georgia
State Board of Workers’ Compensation.
For more
information, please see Frequently
Asked Questions – Workers’ Compensation
Contact: Kathleen S.
Grantham, Esq.
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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
(478)
923-0300