For nearly 100 years, the system of Worker's Compensation has been used in the United States. Worker's Compensation is legislated and administered at the state level. Accordingly, each state has passed their own laws and developed their own system to administer Worker's Compensation within their jurisdiction. Despite the differences of each state's benefits, the overall concept of Worker's Compensation is used in each state.
The model of Worker's Compensation is simple. Employees loose their right to sue their employer for negligence, and employers are required to provide Worker's Compensation to their employees. Specific benefits vary from state to state. All state systems provide some form of protection for employees who are hurt while working.
Prior to the adoption of Worker's Compensation, the previous system required an employee to file a lawsuit against their employer. This proved to be ineffective and problematic. For example, an employee was injured on the job and needed hospitalization and surgery. There would be a loss of income during the recovery period. The employee often had no means to pay for the necessary medical treatment. The only option available was to sue the employer. This is not an ideal situation to maintain a good relationship between the two parties. Bad feelings could easily result. Negligence by the employer was often difficult if not impossible to prove. Employers could defend themselves by claiming an assumption of risk on the part of the employee. (Hood;Hard;Lewis).
The legal process was time consuming and expensive, with no benefits paid to injured workers during the process. Necessary medical treatment was not available to the injured worker. If the worker was successful with the lawsuit, the employer could lose the business and still not be able to provide protection or benefits to their injured worker. (Hood;Hard;Lewis).
The system was unworkable, and this is why the States passed various worker's compensation laws. It provided a statutory solution to the problem. Workers' compensation was a new kind of insurance, which all employers were required to obtain to protect their employees. Insurance was provided by state established and maintained funds, or by private insurers. (Hood;Hard;Lewis).
For example, typical legal language states that in order for an injury to be covered, the harm suffered by the employee must have been caused by an "accidental personal injury arising out of and in the course of employment." Those few words, in this example from the Maryland Worker's Compensation law, are the subject of many court decisions and interpretations. Not all injuries are covered by a Workers' Compensation Law even if the injury happened "on the job." Just because a person is hurt "while working," "on the job" or "at work" may not be enough for the insurance to apply. (North Carolina).
It should also be noted that the compensation laws have evolved during the past century. In addition to traumatic injuries, occupational diseases have become covered under laws and benefits available to the diseased worker. (Hood;Hard;Lewis).
In determining if an injury falls under the coverage of workers' compensation, the first thing to understand is that the law protects only employees. Workers' Compensation statutes provide legal guidance on who are a covered employee and employer. A genuine employer-employee relationship must exist. Once again, the courts have had to decide when someone is or is not an employee. (South Dakota).
Some businesses are established in such a way that some persons do not actually work for the business but work rather as independent contractors. Real estate agents are often considered to be independent contractors, but this area has become fuzzy or blurred because they are "captured" by their broker and not permitted to work for others. (Washington).
Some businesses do not have any employees because they are a sole-proprietorship or partnership. Because of the benefits available to persons in these categories, many states make provisions for them to purchase or obtain workers' compensation insurance. There is often a statutory procedure for electing coverage for those that may not qualify as an employee. (Washington).
Once it is clear that there is an employer-employee relationship between the worker and their company, the next factor considered is if the injury was accidental. An accident is when a sudden, unusual, or extraordinary event causes an unexpected result. The unexpected result is a bodily injury to the employee. The injury had to be caused by an unexpected or unusual event. (Washington).
As stated before, there is an exception to the accident requirement. The exception is occupational diseases. These are illnesses caused by the nature or the circumstances surrounding the worker's job. (Washington).
For example, asbestosis is a disease that could have been caused by a worker doing his job of removing asbestos from older buildings. Some forms of skin, eye, or lung disease may have been caused by a long-term, ongoing exposure to chemical solvents or other solutions used on the job. Conditions such as these could result in the employee's being granted workers' compensation benefits even though there was no specific date of an "accident." They are covered as occupational diseases. (Washington).
In order to receive Worker's Compensation benefits for a compensable accidental injury claim, the injury must "arise out of the employment" of the employee. If the condition under which the work is required to be performed by the employee's employer causes the injury, it is said to "arise out of" the employment. The focus of this aspect is on the exposure of the employee to risk or danger because of the job requirements. For example, if a person must work in an environment that is generally slippery and wet -- such as a car wash facility or a water amusement ride at an entertainment park -- then a slip-and-fall injury experienced by that worker could be said to arise out of the person's employment. (Hood;Hard;Lewis).
The employee's injury must also "be in the course of employment." This is an important phrase. "In the course of employment" is a slightly different factor. The injury must center on the time, place and circumstances of the injury. If the employee's injury occurs during a period of time when an employee was at work, the employer's place of business, or such other location as may have been designated by the employer, and while the employee was performing their job duties or something related to them when the injury took place, the injury is said to have arisen in the course of that person's employment. (Hood;Hard;Lewis).
If all of these factors are satisfied, a worker's injury will generally be covered by workers' compensation insurance. It is not always easy to determine if all of these factors are apparent when an injury is initially reported. Frequently, an investigation of the worker's compensation claim is necessary. If a claim is denied, the states have established procedures for appeals and final adjudication. The procedures vary from state to state. (Hood;Hard;Lewis).
The legislature of each State determines the type and amount of benefits which are payable under workers' compensation. Generally speaking, workers' compensation payments are not taxable to the employee as income. Based upon the laws enacted in each State, insurance companies that provide worker's compensation insurance coverage determine the probabilities of injury for different occupational categories and establish their premium rates. This is the amount charged to employers for their workers' compensation insurance. (Pennsylvania).
While each state is different, generally all the various Worker's Compensation systems offer the following types of benefits:
Temporary Total Disability Benefits: This is the period of time frequently referred to as the "healing period." The amount to be paid is set by the legislature of the state.
Temporary Partial Disability Benefits: These are benefits to which an injured employee may be entitled during the process of recovery when the worker during a temporary period is NOT totally disabled. The amount to be paid is set by the legislature of the state.
Permanent Total Disability Benefits: Some injuries are so serious that a worker is permanently, totally disabled. The amount to be paid is set by the legislature of the state.
Permanent Partial Disability Benefits: Injuries that are not so serious as to leave a worker permanently, totally disabled may nonetheless result in some permanent impairment. This is called permanent partial disability. The amount to be paid is set by the legislature of the state.
Medical/Hospitalization Benefits: In addition to the various types of disability benefits to which an injured worker may be entitled, if a covered employee has suffered an accidental injury, compensable hernia or occupational disease, the employer or its insurer promptly shall provide to the covered employee, as the Commission may require
Medical, surgical or other attendance or treatment:
Hospital and Nursing Services
Crutches and other apparatus
Artificial arms, feet, hands, legs and other prosthetic appliances
Wage Reimbursement Benefits: Some states provide Wage Reimbursement Benefits as part of their Worker's Compensation system.
Vocational Rehabilitation Benefits: When a covered employee is disabled from performing work for which they were previously qualified as the result of an…