Workers' Compensation Act: How to Claim Benefits after a Work Injury

The workers' compensation coverage requirement is satisfied when the injured employee can demonstrate that the injury arose out of the employment, meaning that the employment created the risk of injury, and occurred in the course of employment, meaning that the injury occurred during the time and place of employment while the employee was engaged in activities furthering the employer's interests, and the courts have broadly interpreted these requirements to cover injuries that occur during mandatory employer-sponsored events, during travel for employment purposes, and in some states during recreational activities sponsored by the employer. Workers-compensation and workplace-injury counsel can evaluate whether the specific injury satisfies the statutory requirement of arising out of and in the course of employment, assess whether the employer's insurance carrier has a valid basis for denying or limiting the claim, and advise on the procedural steps required to file a timely and complete workers' compensation claim.

The table below identifies the four principal categories of workers' compensation benefits available under most state acts, the eligibility basis for each category, a description of the benefit, and the law firm's strategic focus for maximizing each category of benefit.

Industrial-accident-insurance and civil-negligence counsel can advise on the specific no-fault benefit structure applicable to the injured employee's claim, assess whether the temporary total disability, permanent partial disability, or vocational rehabilitation benefits are adequate to address the employee's specific injury, and develop the claim strategy for maximizing the total workers' compensation benefit package.

The exclusive remedy doctrine bars the employee from bringing a civil negligence or tort claim against the employer for a workplace injury covered by the workers' compensation system, but the doctrine is subject to well-recognized exceptions that vary by state, including the intentional tort exception under which the employee can sue the employer in civil court if the employer intentionally injured the employee or created working conditions that made injury substantially certain, and the dual capacity exception under which the employer may be sued in its capacity as a manufacturer of a defective product that injured the employee. Employment-and-labor and employee-rights counsel can advise on the specific scope of the exclusive remedy doctrine in the applicable state, assess whether the specific facts of the workplace injury create a viable intentional tort exception or dual capacity exception that would allow the employee to pursue a civil tort claim in addition to the workers' compensation claim, and develop the legal strategy for pursuing the civil claim if an exception applies.

When the workers' compensation insurer denies a claim or disputes the extent of the employee's disability, the employee must pursue the available administrative appeal remedies, and the specific appeal procedures vary by state but typically involve a formal hearing before a workers' compensation judge or board, the right to present medical and vocational evidence, the right to cross-examine the insurer's experts, and the right to further appeal to the state workers' compensation appeals board and ultimately to the state appellate courts. Employment-litigation and federal-employment-law counsel can advise on the specific procedures for filing an administrative appeal of a workers' compensation claim denial, assess whether the insurer's stated basis for the denial is supported by the available medical and factual evidence, and develop the appeal strategy for overturning the denial and obtaining the full benefit award.

The workers' compensation exclusive remedy protection applies only to claims against the employer, and the injured employee retains the full right to pursue a civil negligence claim against any third party whose negligence contributed to the workplace injury, including the manufacturer of a defective piece of equipment, the property owner where the injury occurred if the property was not owned by the employer, and a contractor or subcontractor whose employees or equipment contributed to the injury. Personal-injury and civil-litigation-evidence counsel can advise on the specific procedures for identifying and pursuing a third-party civil claim in a workplace injury case, assess whether the available evidence is sufficient to establish the third party's liability under the applicable negligence or product liability standard, and develop the coordinated workers' compensation and third-party litigation strategy that maximizes the employee's total financial recovery.

A product liability claim in a workplace injury case arises when the employee can demonstrate that a product used in the course of employment was defectively designed, manufactured, or inadequately warned, and the product liability claim is particularly valuable in serious injury cases because it is not subject to the benefit caps of the workers' compensation system and can include compensation for non-economic damages such as pain and suffering that the workers' compensation system does not provide. Product-liability and slip-and-fall counsel can advise on the specific legal theories available for a third-party claim arising from a workplace injury caused by a defective product or hazardous premises condition, assess whether the available evidence supports a products liability or premises liability claim, and develop the liability theory that most effectively establishes the third party's responsibility for the injured employee's damages.

Catastrophic workplace injuries, including traumatic brain injuries, spinal cord injuries, and severe burn injuries, present unique legal challenges because the workers' compensation benefit caps in most states are often inadequate to compensate for the lifetime medical needs, loss of earning capacity, and reduction in quality of life experienced by a catastrophically injured worker, and the catastrophic injury case requires a comprehensive legal strategy that maximizes the workers' compensation recovery while simultaneously pursuing all available third-party civil claims. Catastrophic-injury and wrongful-death counsel can advise on the specific workers' compensation and civil liability remedies available in catastrophic workplace injury or work-related fatality cases, assess whether the applicable state act provides adequate benefits for the catastrophically injured employee's lifetime medical needs, and develop the integrated legal strategy for obtaining maximum total compensation from all available sources.

The employer who engages in conduct that crosses into willful or criminal disregard for employee safety may be subject to criminal prosecution in addition to the workers' compensation obligation, and in a growing number of states the employer's willful violation of a safety regulation that causes an employee's death or serious injury can be prosecuted as a criminal offense carrying fines and imprisonment for the responsible corporate officers. Criminal-negligence and punitive-damages-lawsuit counsel can advise on the specific circumstances under which an employer's conduct can give rise to criminal liability or punitive damages in addition to the workers' compensation obligation, assess whether the employer's willful disregard for employee safety satisfies the applicable legal standard, and develop the legal strategy for pursuing all available remedies.