D.C. Workers’ Compensation Claims: Eligibility, Filing, and Appeals
Private employers with one or more employees are required to carry workers’ compensation insurance in the District of Columbia. As in the rest of the country, the workers’ compensation system in D.C. is a no-fault system designed to compensate injured workers for medical bills, lost wages, and permanent impairments resulting from their injuries. To take advantage of these benefits, injured workers must take certain steps required by D.C. law.
Who Is Eligible for Workers’ Comp Benefits?
Workers’ compensation covers all injuries or illnesses that happen in the course of employment. In general, injuries that happen while you are performing your work duties or running work errands are covered by workers’ comp. On the other hand, injuries that occur while you’re off-duty are generally not compensated through workers’ comp. For example, if you were injured during your lunch break or during your commute to and from work, you will typically not be covered by workers’ comp. For more information, see our article on what types of injuries are covered by workers’ comp.
Workers’ comp covers both traumatic injuries and occupational illnesses. Traumatic injuries are those that result from a one-time accident at work, such as a broken bone from a slip and fall. Occupational diseases are injuries or illnesses that occur over a period of time, including injuries caused by repetitive movements at work (such as carpal tunnel syndrome) and illnesses developed from exposure to toxic substances at the workplace (such as cancer from exposure to asbestos).
What Should I Do if I’m Injured at Work?
If you’re injured at work, you must report your injuries to your employer within 30 days of your injury or within 30 days of realizing that your injuries are work related (for example, in the case of occupational illness). You must complete Form 7 – Employee’s Notice of Accidental Injury or Occupational Disease, and you must provide a copy to your employer and to the Office of Workers’ Compensation.
In addition to giving notice, you will have to file an official workers’ comp claim by completing Form 7A – Employee’s Claim Application. You must provide this form to your employer and the Office of Workers’ Compensation within one year of your injury or one year from the date of your last benefit payment.
In most cases, though, it’s in your best interests to report your injuries immediately. The sooner you give notice, the sooner your workers’ comp benefits can start. And, insurance companies are less skeptical of claims when they are reported right away.
Once your employer receives notice of your injuries, it must complete a form called an “Employer’s First Report of Injury or Occupational Disease” and file it with the Office of Workers’ Compensation within ten days. Your employer, or its insurance company, must accept and begin payments on your claim within 14 days or send you notice of denial.
How Do I Get Medical Treatment?
In an emergency, you can choose which doctor or hospital to seek treatment from. You may also select your treating physician for non-emergency care. However, once you select a doctor, you may not change doctors unless you get the approval of the insurance company or the Office Workers’ Compensation.
What Benefits Can I Receive?
All reasonable and necessary medical treatment related to your work injury will be covered through workers’ comp, including the cost of doctors’ visits, hospital bills, prescriptions, and prosthetic devices. You’ll also be reimbursed for the mileage you incur in traveling to and from medical appointments. In addition to medical benefits, you will also be eligible to receive temporary disability payments and a permanent disability award.
You will be eligible to receive compensation for wage loss during the time you are temporarily disabled and unable to work. Temporary total disability payments are two-thirds of your average weekly wages, subject to a maximum of $1,441.80 per week.
You can continue to receive temporary total disability until your doctor finds that you’ve reached maximum medical improvement (MMI), meaning that your condition has plateaued and is not expected to improve. These benefits are available for a maximum of 500 weeks.
If you’re able to return to part-time or light-duty work while you’re recovering, but earn less than your normal wages, you may eligible for temporary partial disability benefits. Temporary partial disability benefits are two-thirds of the difference in your average weekly wages, subject to the same maximum weekly amount. These benefits are available for a maximum of 260 weeks.
If you are found to be totally and permanently disabled, you will receive the same weekly amount that you received in temporary total disability payments: two-thirds of your average weekly wages, subject to a minimum of $360 and a maximum of $1,441.80 per week. Permanent total disability benefits are available for as long as the disability continues. These benefits are available only to workers with severely debilitating injuries, such as the loss of both hands, feet, arms legs, or eyes. Workers are considered totally disabled only if they cannot earn any wages in the same job or another job.
For most other workers, permanent partial disability benefits are available. You will receive two-thirds of your average weekly wage, up to the maximum weekly amount described above. For injuries to certain body parts, such as the arms, legs, hands, and feet, D.C. has a schedule that lists the maximum number of weeks that a worker may receive benefits. For example, a worker can receive 312 weeks for a total loss of use of an arm. If your doctor gives you a 50% permanent impairment rating of the left arm, you will receive benefits for 156 weeks.
For injuries not listed on the schedule, you will receive benefits only if you can show an actual wage loss. In general, you will receive two-thirds of the difference between your average weekly wage and the wages you are able to earn post-disability.
You may receive temporary partial disability and permanent partial disability for a combined maximum of 500 weeks.
You may also receive a lump sum award of up to $7,500 for a serious disfigurement to the face, head, neck, or other exposed body part.
What if My Claim Is Denied?
If your workers’ comp claim has been denied, or the insurance company is disputing any portion of your claim, you have the right to appeal the decision. To pursue an appeal, you must file a form called an “Application for Formal Hearing” with the Administrative Hearings Division. A hearing will be held before a workers’ comp judge, who will issue a written decision. If you disagree with the judge’s decision, you may file an appeal with the Compensation Review Board.
For more information on the appeals process, see our article on appealing a denial of your D.C. workers’ comp claim.