Welcome to our Workers Comp 101 series! Here we try to explain the basics of workers compensation so you understand your rights. This article is about benefits. Here are some basics on what benefits you get with workers' comp coverage.
A worker who is injured on the job or becomes ill from his work will have his health care for that condition paid under a workers' compensation claim. This care is covered whether or not you lose time from work. It is also paid in addition to any benefits you get for missed wages.
Health care providers must be authorized by the Board to see workers' compensation patients. The Board has lists of providers who are authorized to treat you. The claimant can find a doctor onwww.wcb.ny.gov under Health Care. The providers will send the bills directly to the insurer and the Board. The claimant should not pay any bills unless the Board disallows their case. The claimant may also receive reimbursement for travel to and from a health care provider's office. If specific medical services are disputed, the insurer must pay any undisputed portion. It must also explain in writing why the services were not paid, and request any information needed to pay them. Your doctors may ask you to sign FormA-9. This states you'll pay the bills if the Board does not allow your claim, or if you drop your case before it's accepted.
The claimant can go to any pharmacy, unless the insurer uses a network. Make sure the pharmacist knows the claimant have a workers' compensation case, because many will bill the carrier directly, rather than the claimant. However the pharmacy can ask the claimant to pay for the prescription up front. The insurer must reimburse the claimant within 45 days. The pharmacy can only charge them the amount specified by law, so even if the claimant pays in advance, the claimant will be fully reimbursed. The claimant is not responsible for a copayment.
If the claimant must use an insurer's network pharmacy, the insurer must tell the claimant how to use it. Those pharmacies are paid directly. The claimant will not be responsible for any charges.
Claimants are entitled to benefit awards if one or more of the following are true:
- The work related injuries keep the claimant out of work for more than seven days;
- Part of the claimant's body is permanently disabled;
- Claimant's earnings are reduced because the claimant now works fewer hours or does other
Claimants who are totally or partially disabled due to the injuries sustained at their workers' Compensation accident or the conditions caused by their occupational disease for more than seven days receive benefits for lost wages. The claimant is then entitled to receive biweekly payments as ordered by the judge based on the average weekly wage and the degree of disability. If the claimant does not have more than seven days of lost time, they are not entitled to wage replacement benefits, but, depending on what type of injury they sustained, may be entitled to other types of monetary awards.
The claimant may receive indemnity payments voluntarily before the case is established. When the employer sends the workers' compensation insurance carrier notice of the claim, the insurance carrier may elect to commence payments on a voluntary basis. The amount of these awards should be determined based on the claimant's average weekly wage and degree of disability, but on occasion is not. If the carrier is paying the claimant at a lower rate, we can later litigate this and amend the awards upward.
There is a benefit for the family of workers who die from an injury or illness suffered on the job. The benefit is payable whether the worker dies right after an injury or later.
The worker's spouse and children will receive two-thirds of the employee's average weekly wage, up to the weekly maximum amount. The spouse and children share that weekly benefit; they do not each receive the full benefit. Children receive the benefit until age 18, or until 23 if they attend college. If a child is blind or physically disabled, he or she will receive the benefit for life. The spouse receives the benefit until remarriage. If the spouse remarries, he or she gets a final payment equal to two years of benefits.
The benefit is payable first to a spouse and minor children or dependent grandchildren. If there are no other dependents, then a different benefit is paid. The surviving parents or the deceased worker's estate may be entitled to $50,000. Funeral expenses may also be paid. That benefit is up to $6,000 in metropolitan New York counties, and up to $5,000 in all others.
If a claimant's case is being controverted or disputed, he or she may be entitled to temporary disability benefits. They can obtain these by filing a DB-450 form.
If the case is later established and payment is directed for periods in which the claimant was receiving, the claimant will have to reimburse short term disability for those periods. This means that a portion of the claimant's retroactive benefits will have to go to Short-term disability.
If the claimant's case is ultimately disallowed, the claimant will not have to reimburse short term disability for any payments received.
**This information is based on New York State. Each state may be different. This blog post is for informational purposes. Your specific circumstances may vary from the information provided. Every case is different. Prior results do not guarantee future outcomes. The contents contained in this post do not establish an attorney-client relationship. Please contact us before sending confidential or time-sensitive material**