Am I Entitled to Workers' Compensation Benefits?

Workers' compensation is a type of insurance program designed to assist employees who become ill or injured as a direct result of their job. Every state (except Texas) requires employers to carry workers' compensation insurance, meaning that you can file a claim with your employer to recover financial losses incurred by your workplace injury.

Eligibility for workers' compensation benefits boils down to two basic requirements—you must be an employee of a company that has (or was supposed to have) workers' comp insurance, and you must have been injured at work or as a result of job-related duties. Because there's a lot of myths and misinformation surrounding the workers' comp process, it's best to know what you can and can't recover before you file your claim.

Am I an Employee for Workers' Comp Purposes?

Only employees are entitled to receive workers' comp benefits. It doesn't matter whether you are a seasonal or part-time employee, you're still eligible for benefits. Generally, you don't have to be employed for a certain amount of time before claiming workers' comp benefits. (While some organizations opt to cover their volunteers under workers' comp, it's uncommon, so if you were injured while volunteering, you probably aren't covered.)

Independent contractors, freelancers, or consultants aren't eligible for workers' comp benefits. Keep in mind that if you work a lot of hours for your employer, under their close direction, or at their place of business, you're more likely to be an employee instead of an independent contractor. These distinctions can become very important if you're a "casual" or "temp" worker. Certain salespeople, for example, may be either independent contractors or employees.

If your employer is withholding taxes from your pay, it is treating you as an employee. If your employer tries to treat you as an independent contractor to deny you workers' comp benefits, and you think you may technically be an employee, you may want to contact a workers' comp attorney.

Is My Illness or Injury Covered by Workers' Comp?

Almost any injury or illness qualifies for workers' comp, as long as it's job-related. Common workers' comp claims involve accidents—for example, you strained your back while lifting a heavy object, got your finger caught in a machine, fell on a slippery floor, or were hit by another vehicle while driving.

You can also become sick from unhealthy conditions on the job, like contact with hazardous substances or exposure to toxic fumes. If you become ill over a period of months or years, you can still qualify for workers' comp. For example, typing at a computer keyboard or operating a cash register may, over time, result in a repetitive stress injury (RSI) such as carpel tunnel syndrome.

Chronic illnesses like these, also called cumulative trauma disorders (CTDs), are fully compensable by workers' compensation. Mental illness can also be covered by workers' comp if it's a result of something that happened at work, although it can be difficult to prove.

Does an Injury Have to Happen at Work?

Any time you're doing work for your employer, you're entitled to workers' comp—whether you are at work or not. Here are a few circumstances where you'd be eligible for workers' comp:

• You leave work to pick up office supplies and you get in an accident.
• You're working from home and get injured on your computer.
• You attend the office holiday party and fall down a flight of stairs.

However, your commute isn't considered to be in the course of your employment. So—with rare exceptions—injuries you suffer while commuting don't give rise to a workers' compensation claim. Likewise, when you are out for lunch, you are outside the scope of the workers' compensation system. Horseplay, fighting, and injuries resulting from alcohol or drug use also don't generally qualify for workers' comp.

What If the Injury Was My Fault?

Workers' comp is a no-fault system, so there's no requirement for your employer to be at fault for your injury. Even if you did something to cause the injury—say you always type with your feet up on the desk and you get a back injury as a result—you can still collect workers' comp. But if you caused the injury by intentionally hurting yourself or because you were using drugs or alcohol, your injury won't be covered.

There is a gray area around other situations where your misbehavior causes or contributes to your injury. If your injury is the result of goofing off, your injury may not be covered by workers' comp—unless your employer has condoned this kind of behavior. And if your injury is the result of the fight between you and another employee, the main instigator of the fight will not be eligible for workers' comp. Note that the exact outcome in these types of situations is often highly fact-specific and depends on the workers' comp judges in your jurisdiction.

How Do I Start the Workers' Comp Process?

Though workers' comp laws differ by state, most jurisdictions require an injured or sick worker to notify their employer of an injury within 30 to 45 days of an accident or injury becoming known. If you don't notify your employer within this timeframe, your benefits may be denied.

Notice typically involves telling somebody in a managerial position about the injury. In cases where workers are unable to provide notice—for example, during an extended hospitalization—the notice requirement is generally excused if the employer learns (or should have known) about the worker's injury.

Once the employer has been notified about the worker's injury, the employer should submit a report to the state workers' compensation board or industrial commission and notify the workers' comp insurance carrier. At that point, the workers' comp carrier will be in the position to begin paying an injured or sick worker's medical bills, as well as a percentage of the worker's average weekly income (usually 66%) through the disbursement of temporary disability checks.

Sometimes the process happens differently. A worker may go see the doctor, and when the doctor discovers the medical condition is work-related, the doctor may ask the worker to fill out a workers' comp claim form advising the employer and its insurance company that the worker has suffered a workplace illness or injury. In this case, when you return to work after seeing the doctor, it's still a good idea to tell your supervisor what happened.

Can My Employer Dispute a Workers' Comp Claim?

After you file a claim for workers' compensation benefits, your employer has the right to object. In practice, however, employers usually don't object to claims that are clearly legitimate. Doing so only wastes their time, money, and breeds staff resentment, so most employers have little reason to challenge well-supported claims.

For borderline claims—say an office worker who says they've developed lower back pain due to extended periods of sitting—some employers will challenge these and some won't. Employers must weigh the costs of paying the claim against potentially ruining a relationship with a valued employee. Some employers may dispute the claim based on skepticism about certain types of injuries, or even because they don't like the employee who filed the claim. If you're wondering why your employer objected to your workers' comp claim, it can be helpful to understand why they may have disputed it (and what you can do about it).

Rising Premium Costs

The more workers' comp claims that are filed, the higher the premium costs are for employers. Workers' comp insurance premiums increase when more workers than estimated file for claims, or when an employee has a particularly expensive claim (for instance, they require back surgery). For this reason, employers and their insurance companies routinely use investigative agencies to monitor the daily activities of workers who have filed workers' compensation claims.

Don't be surprised if your public activities are monitored after filing your claim. This could mean an investigator parking outside your house for a few hours to see whether you really appear injured. Investigators have also been known to observe claimants as they attend medical appointments. Be sure to abide by any restrictions your doctor has placed you on in terms of lifting, walking, or other limitations. If you've been prescribed an assistive device, use it and bring it to your medical appointments.

Skepticism of Certain Medical Conditions

Unfortunately, many employers don't believe that some injuries are serious or even valid, especially cumulative trauma injuries. They assume that an employee who files for workers' compensation on the basis of carpal tunnel syndrome, for example, is not being completely truthful or is a "malingerer," the industry term for someone who exaggerates symptoms for financial gain.

Employer bias is particularly strong against injuries involving pain that can't be wholly verified by physical examination, medical imaging such as X-rays or MRIs, lab results, or nerve conduction studies. But this doesn't mean that an injured worker with chronic back pain is malingering. Doctors often need to run extensive tests in order to diagnose an injury, which can take some time (during which the unidentified pain isn't being properly treated).

When it comes to psychological conditions like PTSD, employers often contest the claim because these conditions can be more difficult to objectively verify than physical injuries. They may argue that the mental health condition stems from personal issues rather than the workplace. This is where documentation becomes particularly important.

Dislike of Employee or the Law

Employers might hold grudges against certain employees and treat any claim brought by them as automatically suspect. Regardless, you're entitled to workers' comp whether or not you have a good relationship with your employer, so don't hesitate to pursue your claim.

In addition—with remote working more popular than ever—more employees are filing workers' comp claims based on injuries that happen at home. Most states do allow these sorts of claims as long as the injury is work-related. Carpal tunnel syndrome, for example, could develop while working from home. But an employee who falls down the stairs will have a much harder time proving their claim, even if the fall occurred during work hours.

Procedural Issues

Employers sometimes dispute workers' compensation claims on procedural grounds. Most states require injured workers to report incidents within strict timeframes (typically 30 to 90 days), follow specific notification protocols, and seek approved medical treatment.

Failing to report or document the injury properly, missing deadlines, or seeing unauthorized healthcare providers can severely undermine an otherwise valid claim. You should keep on top of any impending deadlines or other requirements so that you don't lose your chance at obtaining benefits.

What to Do If Your Workers' Comp Claim Is Denied

Workers' compensation carriers can reject your worker's claim. If this happens, you can appeal the rejection of a claim with the state workers' compensation board or industrial commission.If your employer or your employers' insurance company denies your claim, you will be notified in writing. The notice should include reasons why your claim was denied. Some common reasons given for denying a claim are:

• you didn't suffer a serious injury
• your injury didn't take place during work or within the scope of employment
• you don't need medical treatment for your injury, or
• you don't need time off work for your injury.

When you receive a notice that your claim has been denied, call or write to your employer's workers' comp insurance carrier. If this doesn't solve the problem, you can request a hearing with your state's workers' comp board. (Also see our article on what to do if your employer retaliates after you file for workers' comp.)

Contact a Workers' Comp Lawyer

Don't be deterred by your employer's (or their insurance company's) objection to your claim. Employees who have become injured or sick on the job should use the protection afforded to them by workers' compensation. It's your right to have time off work and medical treatment paid for, and if your claim is denied you should fight for these rights with the help of an experienced workers' compensation attorney. Most workers' comp lawyers don't charge a fee up-front—they instead receive a percentage of your benefits if you win your claim—so there's little risk in hiring one to help you file a claim or appeal a denial.