A worker injured on the job may have the right to pursue financial benefits from their employer by filing a workers’ compensation claim. The workers’ compensation system provides employees with specific benefits to help them recover from work-related injuries or illnesses.
In most states, a workers’ compensation claim does not require an injured employee to prove that their employer’s negligence or fault caused the work injury. Instead, the employee has the right to benefits if the injury occurred in the course and scope of their work.
In exchange for these guaranteed benefits, the law makes a workers’ compensation claim an injured employee’s sole legal recourse against an employer, except in limited circumstances.
However, an injured worker may not always immediately receive workers’ compensation benefits after sustaining a work-related injury. Some workers’ compensation claims will take several days for an employer or workers’ compensation insurer to process and pay benefits.
However, when an employer or insurer doubts the work-related nature of an employee’s injury, the employee’s need for specific medical treatments, or whether an injury has disabled an employee from working, a workers’ compensation claim can take weeks to years to resolve.
When an employer or insurer does not promptly assume liability for a work injury or seeks to reduce or terminate benefits before an employee’s injury has healed, an injured employee should seek experienced legal counsel and advocacy from a workers’ compensation attorney.
Initial Steps in Filing a Workers’ Comp Claim
If you suffered an injury at work, filing a workers’ compensation claim involves reporting your work injury to your employer. Many states require workers to report a work-related injury or illness within a specific timeframe, usually within a few weeks or months.
However, workers should immediately report a workplace accident, injury, or illness to their employer. Delaying a report of a work injury or illness may give your employer or the workers’ compensation insurance company reason to question whether your injury or illness occurred due to your job, which may delay the approval of your claim and receipt of benefits.
Waiting too long to report a claim may render you ineligible for benefits. Your employer may have an official form for you to use to report a work injury or illness, or you might report your injury or illness to your supervisor or human resources department.
Even if your employer doesn’t have an official form for you to use, you should still report a work injury or illness in writing to have a record of whom you gave notice and the date you provided notice.
Once your employer receives notice of your work injury, they usually must report the injury or illness to their workers’ compensation insurance provider or third-party claims administrator. In some states, employers must file claim paperwork with the state’s workers’ compensation commission or division. Depending on the state, employees may also have an obligation to file an official claim with the state.
In Alabama, an employer is responsible for filing a First Report of Injury with the Workers’ Compensation Division of the Department of Labor. However, if an employer denies liability for a work injury or illness, an employee can contact the division to speak with an examiner to obtain assistance pursuing a workers’ compensation claim.
Alternatively, an injured worker can hire a workers’ compensation attorney to pursue a workers’ comp claim. A worker has two years from the date they suffered a work injury or last received payment of workers’ compensation benefits to file a claim with the division.
The Review and Appeals Process
When an employer receives a report of an employee’s work-related injury or illness and forwards it to their workers’ compensation insurer or claims administrator, the insurer or administrator will begin investigating and reviewing the employee’s workers’ comp claim.
The employer, insurer, or claims administrator may gather evidence relating to the accident or incident giving rise to the employee’s work injury or illness. This evidence may include accident scene photos, surveillance footage, eyewitness testimony, staffing records, and maintenance or repair records.
The employer or insurer may want to review medical records of the injured employee’s initial treatment, including diagnoses of injuries and the doctor’s causation opinions (if any).
Sometimes, an employer or insurer may ask an employee for additional medical records if the employer or insurer has questions about whether the employee’s injury or illness may have occurred due to a pre-existing condition rather than a work accident.
If an employer or its workers’ compensation insurer or third-party claims administrator denies liability for an employee’s injury, the employee may have the option to request reconsideration or internal appeal with the insurer or claims administrator.
An employee may convince an insurer or administrator to reverse a denial on reconsideration or appeal. However, if an insurer or claims administrator continues to deny liability, an employee or their workers’ compensation attorney may pursue a claim with the state workers’ compensation division.
In certain circumstances, an employer or workers’ compensation insurer may request an employee undergo an independent medical exam (IME). A physician other than the employee’s primary care physician or treating physician will perform the IME, which assesses an employee’s physical condition.
The IME physician will write a report with their findings following the examination. An IME does not provide an impairment rating, a second opinion, or confirmation of a prior diagnosis or treatment recommendation. However, an IME can provide evidence to support an employer’s or employee’s position in a workers’ compensation claim.
IMEs usually occur when an employer wants an employee to return to work or when an employee believes they require additional treatment or rehabilitation for a work injury.
When an employer requests an IME, the employee must submit to an examination scheduled at a reasonable time. Employees who refuse an employer-requested IME may have their claim denied or workers’ compensation benefits terminated. However, the employee can obtain another IME with an independent medical examiner.
Factors Affecting the Timeline of a Workers’ Compensation Claim
Various circumstances will influence how long it may take before an injured worker has their workers’ compensation approved and begins receiving benefits.
Some of the factors that can affect the timeline of a workers’ comp claim include:
- The type and severity of injuries or illnesses suffered
- How long it takes for doctors to diagnose injuries and arrive at a prognosis and treatment timeline
- How long it takes the employee to report the work injury or illness to their employer
- Whether the workers’ compensation insurer or claims administrator requests additional information to process the claim
- How quickly the insurer or administrator investigates the workplace accident and processes the claim
- Whether the insurer or administrator requests an independent medical examination
- Whether the insurer or claims administrator denies liability upon initial review of the claim
- Whether the employee needs to pursue your workers’ compensation claim with the state Workers’ Compensation Division
Frequent Reasons for Delays in the Workers’ Compensation Process
Injured workers can face delays in the processing and approval of their workers’ compensation claims for various reasons.
Some of the top reasons include:
- The employer or the insurer deems the injury or illness not work-related: Getting approved for workers’ compensation benefits can take longer if the employer or the workers’ compensation insurer/claims administrator denies a claim because the employee did not suffer a work-related injury or illness. Employees may need to gather additional information and documentation and pursue reconsideration or a formal workers’ compensation claim to secure benefits.
- The employee delayed reporting the work injury or illness: Waiting to report a work injury will delay the receipt of benefits. However, it can also extend the claims investigation and processing period if the insurer or claims administrator needs additional evidence or has questions about the work-related nature of the injuries.
- The claim involves complex evidence: Processing a workers’ compensation claim can take longer when the claim involves a large quantity of evidence and documentation or complex evidence.
- The employee failed to submit additional documentation or information requested by the insurer or claims administrator: Insurers or claims administrators may delay approval of a workers’ comp claim or deny the claim outright if a worker fails to furnish additional documents or information.
- The worker refused to submit to an independent medical examination: Similarly, a workers’ compensation insurer may deny a claim because the worker refused to attend an IME requested by the insurer.
- The insurer or claims administrator deemed the recommended treatment not reasonable or medically necessary: Obtaining medical benefits from workers’ compensation can take longer when an insurer or claims administrator deems treatment or rehabilitation recommended by the treating physician not reasonable or medically necessary, given the nature of the injuries or illness.
What Benefits Can You Obtain From Workers’ Comp?
Under the Alabama workers’ compensation system, employees who suffer a work-related injury or illness may receive specific financial benefits depending on the nature and severity of their injury or illness.
Most importantly, workers’ compensation includes medical benefits, which pay for all reasonable and necessary treatment and rehabilitation for a work injury or occupational illness, including surgeries, physical therapy, and pain management care.
However, an injured worker must obtain treatment from the physician or healthcare provider selected by the worker’s employer or the workers’ compensation insurer.
An injured worker who cannot work or experiences reduced earnings can also receive weekly compensation benefits, which partially reimburse the worker for lost earnings. Workers can receive two-thirds of their pre-injury average weekly earnings or two-thirds of the difference between their average weekly earnings and their current reduced earnings, capped at the state average weekly wage.
Weekly compensation benefits end when the worker reaches maximum medical improvement, or 300 weeks for temporary partial disability.
For permanent partial disabilities, workers receive payments equal to two-thirds of their average weekly earnings multiplied by the percentage of disability for a certain number of weeks based on the scheduled disability. For permanent total disabilities, workers can continue receiving two-thirds of their average weekly earnings if they cannot return to the workforce.
What Happens After You Return To Work?
Once you’ve reached maximum medical improvement for your work injury or illness or the point at which your treating physician reasonably expects that no further treatment will improve your condition (even if you have not fully recovered), your employer may request you return to work.
Your treating physician may also assign you a permanent impairment rating if you continue to experience some disability of a body part or bodily function. Your disability rating will determine whether you might receive permanent disability benefits and the amount and duration of your benefits.
If you disagree with your treating physician’s or employer’s determination, you might pursue a claim with the state Workers’ Compensation Division or agree to submit to mediation to pursue a settlement.
Expediting the Workers’ Compensation Claims Process
Following specific steps can help move the workers’ comp process along and get you the benefits you need more quickly:
- Report a workplace accident or work injury/illness as soon as possible. Waiting to notify your employer of your work-related injury or illness may delay processing your claim if the workers’ compensation insurer or claims administrator can’t obtain specific evidence or information due to the delay. A time delay between when the injury occurred and when you reported it may give the insurer or claims administrator reason to question whether the injury occurred in the course and scope of your work.
- Gather any relevant information or documentation, such as medical records of initial treatment, evidence from the workplace accident scene, or names of co-workers or witnesses who saw the accident or have information about your injury. These documents and information can speed up the claims process.
- Schedule an IME as soon as possible if your employer or the workers’ comp insurer requests one.
Finally, contact a workers’ compensation attorney if your employer or the workers’ compensation insurer does not promptly accept liability for your work injury or illness. Insurers can give injured workers the runaround when processing workers’ comp claims.
A personal injury lawyer in Huntsville can communicate with insurance or claims adjusters, moving the claim forward while protecting your rights and interests.