10 Things to Know About Workers’ Compensation

A worker uses a tool on a construction site. (Stock photo)

When you slice off your finger working in the deli, fall off your executive chair and crack your skull, or develop an illness because of your job, workers' compensation is supposed to cover your medical costs and pay you for any days of work you miss.

Almost all employers have to buy workers' comp insurance. But workers' comp doesn't cover everyone on the job. Agricultural workers, domestic workers and independent contractors are among those who are sometimes excluded.

To be covered by workers' compensation, you must be an employee and be accidentally injured while doing your job or get sick from doing your job, like being exposed to asbestos from ripping out ceiling tiles while doing renovation work.

"Just because an injury happens at your job doesn't mean you're automatically entitled to benefits," says Rebecca Shafer, president of Amaxx Risk Solutions, a workers' compensation consulting firm in Hartford, Connecticut.

If your co-worker's wife comes to your workplace, fires a gun at her husband and hits you, you're probably not covered because the injury had nothing to do with your job. However, if your co-worker comes to the office with a gun to shoot your boss and accidentally hits you, then you're likely covered, Shafer says.

How can you make sure you get the workers' compensation you deserve? Here are 10 things to know:

1. Report Every Injury or Illness

Always report any work injury or illness your doctor says is due to your job. "It's not enough to report it to the guy working next to you," says Tricia Kagerer, a workers' comp expert and vice president of risk management for Jordan Foster Construction in Dallas.

Report the injury or illness to the human resources department, your supervisor or the risk-management department when it occurs, she says. "You should get an incident report to fill out, and they should help you obtain medical treatment," she says.

If you don't get paperwork or a call from an insurance adjuster, something is wrong. Follow up with your boss.

2. Visit the Right Medical Provider

If your injury is an emergency, you'll go where the ambulance takes you. In a non-emergency, your employer may direct you to a particular hospital, clinic or doctor. Go where your employer tells you or your bills may not be covered by workers' compensation, Shafer says.

3. Tell the Doctor or Hospital Employees You Were Injured on the Job

When you're filling out the paperwork at the hospital or doctor's office, check the box that asks whether your injury happened at work. That gets your medical bills sent either to the workers' compensation insurance company or your employer, rather than to you.

If you choose your own doctor, be sure they're approved or certified to do workers' compensation claims and have agreed to the workers' comp pay schedule.

4. Make Sure Your Medical Records Include Everything About Your Injury

Your medical records should mention the history and circumstances of your injury or illness and list every body part involved. Workers' compensation won't pay to treat body parts that aren't listed, says Ed Scheine, a Hauppauge, New York, workers' compensation attorney.

5. Ask Your Employer to Explain Its Workers' Comp Coverage

Your employer most likely has a brochure explaining the workers' compensation program. Get it and read it. Next, find your state's workers' compensation office and check out the information on its website, says Bryan Thomas, CEO of Cannon Cochran Management Services, a Danville, Illinois, risk-management and claims administration firm.

6. If Your Employer Says You're Not Covered Because Your Accident Was Your Fault, It Might Be Lying

Workers' comp is no-fault insurance, so you're covered even when the accident is your fault. "If you're at work and you slip and fall on a banana peel, they can't deny your claim because you should have seen the peel," Kagerer says.

However, there is a limit to how stupid you can be. If horseplay is involved -- say, a co-worker dares you to jump out the window and you break your leg doing it -- workers' compensation won't cover you in some states.

7. Stay Sober at Work

In a similar vein, if you get high on your way to work and then slice your finger off later that day, you'll be paying your own medical bills. Most employers require a drug test after an accident; if you test positive, your claim will be denied.

8. You May Not Need an Attorney to Get What You're Owed

States set workers' compensation payouts, so there's not a lot of leeway for you to get more (or less) than you deserve. In New York, for example, a thumb is worth 75 weeks of pay. If your thumb is 10% disabled in a workplace accident, you get 7.5 weeks of disability. "The value system is built into the law, and the doctor decides how permanent your injury is," Scheine says.

A workers' compensation attorney will take at least 20% of your settlement, so don't hire one unless you think you're being shortchanged over a permanent disability, have a complex claim or were unfairly denied coverage of your medical bills.

Even then, most states have a workers' compensation ombudsman who can help you get what you deserve from the system.

9. Big Payouts Are Rare

In Texas, the maximum workers' comp benefit for lost pay is $725 a week, Kagerer says. That's fine for a minimum-wage worker, but it doesn't come close to replacing a chief financial officer's salary.

10. (Most) Cheaters Eventually Get Caught

Cheating is so common in workers' compensation that there's a term for it -- malingering -- as well as fraud divisions to look for it. "[Malingerers] get caught because insurers and employers make home visits, do surveillance and see if other companies are contributing to your Social Security," Shafer says. "It may take awhile, but chances are pretty good you'll get caught, and if you do get caught, it can mean jail time."

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