Resource Guide

Introduction

Part 1: The Workers' Compensation Process

Part 2: Special Issues In Workers' Compensation

HOW DO I KNOW IF I HAVE A WORKERS COMPENSATION CLAIM?

Three elements are required for a valid Workers Compensation claim. First, you must either have an accident while on the job or an occupational disease. Second, you must give timely notice to your employer and third, you must have medical evidence proving that your condition is the result of the accident or occupational disease. Each of these topics is discussed in more detail below.

Accident

An employer is only responsible for injuries caused by work-related accidents. In order for an injury to be "compensable", meaning covered by Workers' Compensation, it must occur in the course of employment and also be related to the work. Accidental injures can be both physical and psychological. Injuries that occur when another employee intends to cause injury and injuries that are the result of intoxication while on the job are not covered by Workers' Compensation.

Examples:
  1. Joe works for a construction company. He falls from a ladder while installing dry-wall and breaks his arm. This is a straightforward claim. Joe was at work when he fell, and he was involved in a work activity when the accident took place. Now, assume that Joe doesn't fall off the ladder, but instead takes a break and walks to a nearby coffee shop. On the way, he trips on a curb, falls down and breaks his arm. This case is not as clear. Although the accident happened during the workday, and very close to the job site, it may not be covered by Workers' Compensation because Joe was not in the course of his employment or performing an activity directly related to his work. However, if Joe's boss told him to go get coffee for everybody, he might be covered.
  2. Mary is a police officer. During the course of her duties she and her partner areinvolved in a high-speed chase, and motor vehicle accident. Mary witnesses herpartner's death, and is later diagnosed with post-traumatic stress disorder. Mary'sclaim will most likely qualify as a work related psychological condition.Now, assume that Mary isn't involved in a car accident, but is assigned to the police department's file room. She is constantly being reprimanded by her supervisor for failure to get her work done on time, and is demoted. The demotion causes her significant stress so she goes to see a psychiatrist and is diagnosed with a work related anxiety disorder. Under these circumstances, Mary will probably not be covered by Workers' Compensation because the law does not provide coverage for work related stress claims which are based on lawful personnel decisions such as disciplinary action, work evaluation, job transfer, demotion or termination. As you can see, it is not always clear whether an injury will be covered by Workers' Compensation, therefore, it is important that you contact your attorneys whenever you get hurt at work and let us know all the facts and circumstances involved.

Occupational Disease

If there is no accident, the only other way to establish a valid claim is to show that theemployee has contracted a "disease" from his employment. Common examples of occupationaldiseases are carpal tunnel syndrome and similar conditions brought on by repetitive use of abody part; diseases caused by prolonged exposure to chemicals and other substances; andhearing loss from occupational noise exposure.

Notice

The law requires an injured employee to provide written notice of an accident to hisemployer within 30 days. Notice of an occupational disease should be given to an employerwithin 30 days of the first indication that it is work related. Despite these legal requirements,failure to inform your employer of an accident or occupational disease does not automaticallyend your claim. If 30 days have gone by and you haven't reported an injury, you should do so assoon as possible.

Causal Relationship

In order to prove causal relationship, an employee must have a medical report describing his work accident, diagnosing his condition, and then explaining how the diagnosis relates to the accident. In order to prove causal relationship in an occupational disease claim, the doctor must provide a detailed description of the injured person's work, diagnose a condition, and then explain how the work duties caused the condition. Because of the causal relationship requirement it is crucial to have strong medical evidence in every case. You should see a doctor as soon after your injury as possible, and maintain a schedule of follow-up appointments.

A common problem in the causal relationship category occurs when a significant period of time elapses before an injury becomes evident. For example, a worker could injure his back lifting a heavy object, and due to extreme back pain, not realize that he also injured his shoulder in the same incident. His initial medical records may only reference the back injury, making it more difficult to prove the shoulder injury later. The best advice we can give is to discuss all possible injuries with your doctors as soon as possible.

If you believe you can prove the factors discussed above; accident or occupational disease, notice and causal relationship, you probably do have a valid Workers' Compensation claim. The next section of this booklet will discuss how to file your claim. If your employer and its Workers' Compensation insurance carrier disagree with you, they will "controvert" your claim. This means that they will refuse to pay benefits and request a hearing before a Workers' Compensation Law Judge. The hearing process will be discussed on pages 8 and 9.