At any given time, there are millions of people working in the U.S. Unfortunately, accidents happen and workers get hurt. According to the Bureau of Labor Statistics, private employers reported more than three million nonfatal workplace injuries in 2013. Fortunately, every state requires most employers to provide workers’ compensation coverage for their workers. Although every state’s rules are different, the claims process for receiving benefits is similar across the board.
Who May File a Claim
Employees with work-related injuries may file claims for benefits. The workers’ compensation system is different from lawsuits filed in court, in that the employee doesn’t need to prove that the employer was at fault for the injury. As long as the injury happened while the employee was performing a job-related task, the employee is eligible to receive benefits.
In the case of a fatal work-related injury only, the employee’s spouse, children, or other dependents may file a claim for death benefits. The main purpose of death benefits is to compensate the employee’s close family members who relied on the employee for financial support. In addition to death benefits, family members can usually receive a small sum to cover burial and funeral expenses for the employee.
How to File a Claim
You must notify your employer (and possibly your state workers’ compensation agency) of your injury soon after it happens. Many states give the worker a certain amount of time; for example, in California, the worker has 30 days to report an injury. Other states don’t give a specific deadline, but require the worker to give notice as soon as it is practical. If you fail to give notice on time, you could be denied benefits. To be safe, it’s best to give notice immediately after you have suffered a work-related injury.
Most of the time, you don’t need to follow any special format when notifying your employer or state agency of your injury. However, some states, such as New York and California, require the worker to provide written notice. As a practical matter, though, it’s always a good idea to give written notice and keep a copy of it for your records.
In some states, this will be the official start to your workers’ compensation claim. In other states, including Illinois, California, and New York, you will need to fill out an official claim form and give it to your employer or send it to the state workers’ comp agency. (See Workers' Comp Claims FAQs for more information.)
Receiving a Response
While some, larger employers are self-insured, most employers purchase workers’ compensation policies through insurance companies. The employer will notify the insurance company about your injury, and the insurance company will handle the processing of your claim.
The insurance company typically has three options: it can accept your claim, deny your claim, or ask for more time to gather information. If your claim is accepted and you are off work for more than a few days, the insurance company will start sending you weekly temporary disability benefits. (See Workers’ Comp Benefits FAQ for more information.) If your claim is denied, the insurance company will send you a letter stating the specific grounds for the denial. To receive benefits, you will need to file an appeal with your state’s workers’ compensation agency.
To appeal a decision by the insurance company, you’ll need to file appeal paperwork with your state’s workers’ compensation agency. The paperwork goes by different names, but is usually called an appeal, petition, or request for hearing. Because the appeals process can get complicated, most workers hire lawyers at this stage. Your lawyer will gather evidence by requesting documents, interviewing witnesses and doctors, and sending written questions to the insurance company. The insurance company will do the same, which often includes having you undergo a medical examination by a doctor of its choosing. (See Tips for Handling Your Independent Medical Examination for Workers' Comp.)
At the hearing, lawyers for both sides will present evidence, question witnesses, and make legal arguments. An administrative law judge (ALJ) or another official from the state workers’ comp agency will preside over the hearing and make a decision, usually within a few weeks. If you disagree with the decision, you can usually appeal higher up within the agency or in state court.
Workers’ compensation claims can be complicated, and insurers often fight tooth-and-nail to avoid paying benefits. In many cases, employees will need expert opinions from doctors and other professionals to prove the extent of their injuries and how much they should be paid. Make sure you get all the benefits to which you’re entitled by understanding how the process works and consulting a lawyer for help with your claim.