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Understanding Workers’ Compensation Claims

Can I File a Workers Compensation Claim?

Florida law requires that most employers carry workers’ compensation insurance. Exceptions to this rule are companies with fewer than four employees (if not in the construction industry – all construction companies, regardless of size, must carry workers’ compensation insurance), state or local governments, or if the employer is a farmer with five or fewer regular employees and/or fewer than twelve seasonal workers who work for up to 30 days in a season but no more than 45 days in a calendar year. Workers’ compensation is intended to provide employees with compensation for injuries they suffer on the job, regardless of fault. The workers’ compensation policies companies purchase make employers immune from certain lawsuits. The benefits to which employees may be entitled include compensation for medical bills and/or disability, as well as death benefits payable to a deceased employee’s family or estate. The amount of compensation an employee is eligible for is capped at an amount established by law each year. In 2019, that amount was $939 per week.

Filing a Workers Compensation Claim

When an employee reports a workplace injury to their employer, the employer must then submit a claim to their workers’ compensation insurance plan. Under Florida law, an employee must report an injury within 30 days of receiving it. In circumstances in which the injury is not immediately apparent but develops over time, the employee must notify the employer within 30 days of discovering the injury and demonstrate that it was related to the employee’s work. Late filing of a claim can result in a reduction or complete loss of benefits. Give your employer as much information as you can when filing your claim. Critical information includes the date of the accident, how you were hurt, and the symptoms you are now experiencing. A workers’ comp lawyer can help you do this.

After You File Your Workers Comp Claim

Once you report your injury to your employer, your employer is responsible for sending you to a doctor. Florida law allows the employer to choose the doctor if you don’t require emergency care, making it important that you provide detailed and accurate information about your injuries and how severe your symptoms are so that you can see the right provider. It is the employer’s responsibility to notify its insurance company of your claim within 7 days of when you file it. Sometimes, unscrupulous employers fail to report claims. If yours refuses to file, you have the option of contacting the insurance company directly. After your employer’s insurance company is notified by either your employer or by you, it will then begin an investigation of your eligibility for benefits. This investigation will likely include tasks such as:

  1. Analyzing your education, income, and employment experience or areas of expertise.
  2. Reviewing the medical records related to your injury and possibly previous records if you’ve had similar injuries in the past.
  3. Requiring you to partake in a functional capacity evaluation to assess your ability to carry out your work duties and responsibilities.
  4. Ordering a medical evaluation to assess your current condition and symptoms.

Insurance companies must promptly approve or deny employees’ worker compensation claims. If the insurance company approves the claim, they must begin issuing benefits promptly as well, including disability and other types of benefits.

Types of Workers’ Compensation Benefits

Broadly, there are three different types of disability compensation under Florida law: temporary disability; temporary impairment disability; and permanent total disability. You may be awarded additional benefits including vocational rehabilitation or medical benefits. Your family may receive death benefits if a loved one is fatally injured on the job. In general, these benefits are tax-free to the recipient.

Temporary Disability

Temporary disability benefits are basically what they sound like—they pay you for the time you need away from work to recover from an injury you received on the job. Insurance companies are not required to pay benefits for the first 7 days you are out of work unless your injury prevents you from returning to work for more than 21 days. To receive temporary disability payments, a person must remain under a “no work” status or have limitations that the employer cannot accommodate. The amount of compensation you will receive is two-thirds of your average weekly earnings up to the legal maximum. For 2019, the maximum is $939 per week; for 2020, the maximum increases to $970 per week. The minimum is $20 per week. Some employees may qualify for 80 percent of their income before suffering their injury for the first six months if they suffer blindness, paralysis, or certain other serious injuries. If an employee qualifies for this higher benefit, there is no maximum. As the name implies, these benefits are temporary—they discontinue at either 104 weeks (2 years) or 260 weeks (5 years) depending on the circumstances. Before reaching the time limit, your benefits will be discontinued if your doctor clears you to go back to work or determines that your condition will not improve even if you receive additional medical treatment. This stage is referred to as the maximum medical improvement (MMI) you are likely to be able to achieve. The 104-week limit applies if you have not reached your MMI. If you have reached your MMI and are unable to return to work, or have to work with restrictions that lower your earnings, the 260-week time limit is applicable. If, after reaching your MMI, you earn less than you did before your injury, your benefit amount changes and you can receive 80 percent of the difference between what you are currently earning and 80 percent of your pre-injury earnings.

Permanent Impairment Benefits

If you complete medical treatment because your injury is healed or you have not reached the MMI stage for your particular injury six weeks before your temporary disability benefits running out, the doctor treating you will evaluate you and the current state of your injury. The doctor will provide a determination regarding whether or not you have a lasting medical condition or impairment. If your physician determines that you can work at some level, they assign what is called an impairment rating. This rating is expressed as a percentage and is used to figure out how long into the future your benefits will last. Florida law sets forth a formula that is used to make this determination. The math is not complicated necessarily, but does take into consideration several factors. The amount of weekly benefits you receive is 75 percent of your disability rate, not to exceed the maximum established by law. However, that amount is halved if you are currently earning as much or more than you did before being injured.

Total Permanent Disability

Sometimes work-related injuries are severe enough that the person who suffered the injury has a permanent injury that keeps them from doing even sedentary jobs. Extremely serious injuries such as severe brain injuries or amputations qualify automatically as permanent disabilities. A person with a permanent, severe injury can qualify to receive permanent total disability payments. These are paid at the same rate as temporary disability benefits and continue until the recipient reaches 75 years old. In situations in which the person doesn’t qualify for social security benefits, they will receive disability payments until their death.

Vocational Rehabilitation

In certain cases, injured employees may qualify for vocational counseling, replacement services, and other help finding a new job or line of work if they are unable to return to their pre-injury job. Recipients are limited to either 26 or 52 weeks of vocational rehabilitation benefits, depending on the severity of their injuries.

Medical Care Benefits

An employer’s workers’ compensation insurance must pay for medical care necessary to diagnose and treat an employee’s work-related injuries if the treatment is prescribed by the doctor treating the patient and approved by the employer’s insurance company. Employees can also receive compensation for travel to and from medical appointments and for what it costs to go pick up prescriptions.

Death Benefits

Florida law recognizes the hardship that a work-related death places on that person’s family and requires insurance companies to pay benefits to the deceased person’s spouse, dependent relatives, or children. While the amount varies depending on how many dependents the person had, the maximum allowable benefit is two-thirds of the person’s average income earned on a weekly basis, subject to the same limits as temporary benefits. The total benefit may not exceed $150,000. Families can also receive up to $7,500 for the cost of the funeral and other burial costs they incur.

When Benefits Are Denied or Are Insufficient

Florida Workers' Comp Claim LawyersInsurance companies, while not inherently evil, do have a vested financial interest in paying out the smallest amount of money possible for workers’ compensation claims, and do deny filed claims for seemingly ridiculous reasons. In addition, as discussed above, no type of workers’ compensation benefits pays 100 percent of the injured person’s pre-injury income. This shortfall can result in financial hardship for injured employees and their families who may feel like they have no way out from under the seemingly overwhelming burden of medical debt and adjustment to their new post-injury normal. So, what can you do if you are unable to pay your bills or your claim is denied entirely?

Appealing a Workers Compensation Denial

The Florida Division of Workers’ Compensation (DWC) oversees all workers’ compensation claims filed in the state. If your employer’s insurance company denies your claim, you have a right to appeal the decision to the DWC. This requires the employee to file a Petition for Benefits within two years of the injury or one year of the last income loss or medical payment, whichever is later.

Filing a Lawsuit Over Workers Compensation

Any injury can leave the injured person with lifelong challenges and long-term medical expenses. Even though workers’ compensation is intended to cover those expenses, it will not always be sufficient and is subject to limits. Medical expenses can overwhelm you just as much as the physical pain you suffer as a result of your injuries. Your workers’ comp lawyer can analyze your case to determine if your workers’ compensation insurance company is making bad-faith attempts to delay, deny, or reduce the benefits to which you’re entitled. If so, your attorney may advise you to take the insurance company to court. In addition, third parties may cause some workplace accidents—a negligent equipment company that built, designed, or sold a defective product, for example, or another firm that’s working on the same jobsite. If that happens, your attorney may advise you to file a claim against those third parties in an attempt to recover additional compensation for the harm they caused you. Despite lawmakers’ intention to create a simple system for the recovery of workers’ compensation benefits, these claims are incredibly complicated, as the above demonstrates. Calling an experienced workers’ comp lawyer can help you understand the process and how to work through it so you can recover the benefits you deserve. Sibley Dolman Gipe Accident Injury Lawyers, PA 800 North Belcher Road Clearwater, FL 33765 (727) 451-6900 https://www.dolmanlaw.com/florida-workers-compensation-attorneys/