Who Is Eligible for Workers Compensation?

Workers compensation is a no-fault insurance program designed with two things in mind: One, provide wage replacement and medical compensation for employees injured or sickened in the course of their employment. Two, prevent injured workers and employers from taking disputes over fault or negligence to court.

Workers comp is mandated in every state, but Texas and South Dakota. Generalities apply across the board, but because they are state-directed, plans vary, right down to who qualifies for coverage. Workers compensation eligibility can, literally, come down to where you live and, more important, where you work.

The good news is, if you qualify, you can reasonably expect the following benefits to kick in once your claim is approved:

• Medical treatment for injured employees.
• Relief from occupational hazards, such as exposure to disease.
• Temporary disability compensation.
• Permanent impairment compensation.
• Total disability (often a lump-sum payment).
• Death benefit.

Keep this in mind, says Steve Franco, an Oakland, Calif.-based workers comp lawyer: “Medical benefits can last for life, in theory. If you sustain an injury while at work, you can enter an agreement whereby a workers’ compensation insurance carrier is responsible to administer medical bills corresponding to the body parts that you injured for the remainder of your life.

“There are rules and procedures in terms of how medical treatment is authorized and requested,” Franco adds, “but in theory, an individual can choose to have medical benefits covered for life.”

So, who’s eligible? Let’s dive in.

Workers Compensation Eligibility

Typically, several factors determine whether an injured (or sickened) worker is eligible to file for workers compensation. The following are generally accurate, but their application hinges on assorted state-specific factors. For instance, if you live in far east Alabama and work across the state line in Georgia, Peach State workers comp laws apply.

It’s even more complicated in Texas and South Dakota, where — despite the availability of workers comp insurance — employers are not required to participate. And then there are the minimum-employee statutes in Alabama (at least six) and New Mexico (at least four) that must be met before the employer is required to participate.

With these nuances in mind, let’s explore what typically applies to sorting out who’s eligible to make a workers comp claim.

Your Injury Must Be Work-Related

Workers compensation benefits apply only to injuries and/or conditions that are connected to work. Within that scope, almost anything applies. You slip. You fall. A piece of equipment malfunctions, resulting in injury. You’re covered.

Even this: You’re on a ladder as part of your duties and roughhousing colleagues cause you to tumble. They’re in trouble, but your injuries are covered. If it turns out you were in on the prank, however, your claim may be denied.

Repetitive motion injuries, in which some part of the body breaks down from the cumulative effects of performing the same duty for prolonged periods — typing on a keyboard, stocking shelves, practicing a musical instrument, manipulating precision tools — are covered as well.

Severe mental and emotional stress — a common enough malady during the peak pandemic years — also may be covered. But proving it can be difficult.

Reporting the injury in a timely fashion (more about that below) also is crucial. Claiming you strained your back at work two weeks earlier when you were telling colleagues about a collision during an intervening weekend softball tournament, could put your claim in jeopardy.

If you’re injured while driving for work, whether it’s a company vehicle or your personal car, you’re most likely covered. But if you’re in an accident while commuting, that’s not a workers comp event.

In summary, most work-related injuries or illnesses are fairly straightforward. Occasionally, however, the circumstances can be murky. That’s among the reasons it’s never a bad idea to consult a workers comp attorney early in the claims process.

You Must Be an Employee

Workers comp insurance applies only to employees. So, who is an employee? Generally, if the boss has a significant amount of control over your work circumstances, you’re most likely an employee. This, too, can get murky. Independent contractors — freelancers, consultants, most members of the “gig” economy — fall outside the guidelines of being an employee.

This bears watching, as legislatures pursue reform measures that pull certain gig workers, such as drivers for ride-hailing services, are reclassified.

Moreover, watch out for employers who misclassify workers as independent contractors to save on payroll taxes and workers comp premiums. Even if you’ve received a 1099 tax form in the past, or you’re in line to get one this year, you may yet have claims on the company’s workers comp insurance. This one’s likely going to court. Again, you’re going to need legal representation.

Your Employer Needs to Have Workers Comp Insurance

With rare exception (some mentioned above), employers are required to have workers compensation insurance. States that require employers to have workers comp face significant penalties — fines, work stoppages, even prison — if they’re discovered to be shirking their responsibilities.

Most states have searchable online databases that list employers with active workers compensation insurance policies. In your favorite internet search engine, type the name of your state (or the state where you report to work) and workers compensation verification to begin.

Here again, because they have expertise such searches — especially when you work in one state, live in another, and the company’s headquarters is somewhere else altogether — enlisting the early aid of a workers compensation lawyer with local expertise is in your favor.

If you discover the worst — your employer’s policy has lapsed, or the owner never had one in the first place — you’ll have decisions to make. Should you file for compensation from the applicable state’s uninsured employer fund, or file a personal injury lawsuit against the employer?

You can do one or the other, but It’s unlikely you will be allowed to do both.

“It is a very complicated process since it involves the intersection of both workers compensation law as well as personal injury,” says New York-based workers comp attorney Matthew Sullivan.

“If you bring a lawsuit against your employer,” Sullivan says, “you can fully expect the employer to hire an experienced defense attorney because the stakes will be high for the employer. If they are found liable for your injuries, and lack insurance, then they may be personally responsible for paying any award or verdict. They may also face criminal consequences for failing to obtain workers compensation insurance.”

Again, proceed only after consulting a workers compensation or personal injury attorney. Not only will the lawyer be able to provide insight into your best option, (s)he may identify actionable negligence on behalf of a third party — an outside provider of machine maintenance, for instance — that contributed to your injuries.

You Must Report Your Injury Before the Deadline

There are deadlines, and then there are deadlines. Whether it’s an injury-producing accident or the onset of work-related bursitis or emphysema, it’s always best to report the incident or the recognition of pain sooner rather than later.

Tell your supervisor as soon as it’s practicable, but certainly  — in most states — before 30 days have elapsed. Pro tip: Put the report in writing, which is always better than having a conversation. Specify the date and location of your accident or injury (or first noticed the onset of your illness or pain). Failure to report early on may jeopardize your claim once it’s filed.

The deadline deadline involves when you must file your claim. In most states, you’re OK if you file within 12 months. Twenty-two states allow two years; Minnesota gives claimants six years.

As much as possible, be proactive. Take notes. Keep receipts. Track progress on a calendar. Photograph the area that is the source of your injury or illness. In short, do your best to stay ahead of the process. If your condition will not allow you to take all this on, consider recruiting a responsible friend or family member, or retaining a workers comp lawyer.

How to Get Workers Comp

The written report of your injury, whether instantaneous, the result of repetitive motion, or prolonged exposure to hazardous conditions, should include the following:

• Your name.
• Your address.
• Your department and/or division.
• Time and place of the accident.
• A brief description of how your accident occurred.
• The type of injury, or injuries, you suffered.
• All places where you are having pain, numbness, tingling, or swelling.

 If you present a paper report, make certain you receive a time-stamped copy. If you sent your report via email, include a notification for receipt, and keep a copy.

If your employer provides forms for you to complete, make certain you retain copies for your records. Even for seemingly minor incidents — a stumble on loose carpet; a finger bruised in a door that closed unexpectedly; a hand cut fixing a printer paper jam — you (and your employer) will want documentation. If subsequent symptoms interfere with your ability to perform your job, everyone’s going to want to have a record of the initiating event.

Your employer may provide forms for you to complete. Make certain you retain a copy for your records. Even if your work-related injury seems minor — you punctured your finger with a stapler; you twisted an ankle on loose carpet — you’ll want documentation if, later on, symptoms induced by the episode interfere with your ability to perform your job.

When it’s clear the evidence supports that your injury or illness qualifies as work-related, you’ll be summoned to fill out a claim form. This may be supplied by your employer, but in most states, the forms will be available at doctors’ offices and emergency rooms as well. If all else fails, contact your state workers compensation office for the form and, perhaps, instructions for completing it.

Most likely, you’ll be referred to a medical professional to verify your condition, and to ascertain whether it was work-related. This process will involve additional forms. Make sure they identify your injury or illness as work-involved.

After that, your employer will gather the relevant documents (of which you have copies) and file them with its workers comp insurer.

Then you and your employer wait — usually two to three weeks — for the insurer to rule on your claim (accepted/denied) and go from there.

With your attorney already on board, of course, you will spend the time in complete confidence of a satisfactory outcome.