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Workers’ Comp Claim Coverage & Criteria

Workplace injuries or illnesses can have a significant impact on an individual's health, well-being, and financial stability. Workers' compensation serves as a crucial safety net, providing support for medical expenses and lost wages when employees suffer job-related injuries or illnesses. In this article, we'll review the types of expenses that a workers' comp claim can cover.

One of the core aspects of workers' compensation is the reimbursement of medical expenses incurred as a result of the work-related incident. In this article, we will delve into the array of expenses that are commonly reimbursed in a workers' comp claim, shedding light on the key categories and considerations involved.

Picture of money and medical masks for the blog about filing a workers' comp claim.

What a Workers' Comp Claim May Repay

It's important to note that the specific coverage and limits of workers' compensation benefits can vary significantly depending on the laws of the jurisdiction where the injury occurred and the nature of the injury itself. The North Carolina workers' comp claim portal has online resources for how to handle the process. It's recommended to consult with professionals, such as a personal injury attorney or workers' compensation lawyer, to fully understand the coverage available in your particular situation.

As a quick overview, workers' comp claim coverage includes:

  • Medical expenses
  • Lost wages
  • Ongoing care costs
  • Funeral expenses

1. Medical Expenses Coverage

If you file a workers' comp claim to get your medical expenses financially accounted for, you may be reimbursed or compensated for any of the following types of bills:

  • Approved doctor's visits
  • Hospitalization
  • Surgery
  • Doctor-prescribed medications
  • Rehabilitation and therapy
  • Testing

A. Doctor's Visits

Workers' compensation typically covers visits to healthcare providers, including doctors, specialists, and other medical professionals. These visits may involve initial assessments, follow-up appointments, consultations, and evaluations of the injury's progression.

It's important that you speak with your employer about the approved healthcare providers. Choosing a doctor will impact the outcome of your workers' comp claim, so make sure it's an approved provider.

B. Hospitalization

In cases where the injury or illness requires hospitalization, workers' compensation can reimburse expenses related to room and board, surgical procedures, anesthesia, and any necessary medical treatments administered during the hospital stay. Be sure to keep documentation of these procedures for your workers' comp claim.

C. Surgery

If surgery is deemed necessary to treat the work-related injury or illness, workers' compensation can cover the surgical costs, including the surgeon's fees, operating room expenses, anesthesia, and post-operative care.

D. Prescription Medications

Workers' compensation commonly includes coverage for prescription medications prescribed by healthcare professionals as part of the treatment plan. This extends to pain management, antibiotics, and other medications essential for recovery.

E. Rehabilitation Services

The journey to recovery often involves rehabilitation services such as physical therapy, occupational therapy, and rehabilitation equipment. Workers' compensation can reimburse the expenses associated with these services, aiding in the restoration of physical functionality.

F. Diagnostic Tests

Medical imaging and diagnostic tests like X-rays, MRIs, CT scans, and lab tests are frequently required to accurately assess injuries and monitor progress. These costs are typically covered as part of a workers' compensation medical claim.

2. Temporary Disability Benefits

If your injuries leave you in a position where you qualify for disability, you may be able to receive disability benefits as part of your workers' comp claim. Temporary disability benefits are not intended to provide the same level of compensation as regular wages, but they serve as a critical lifeline for injured employees by helping them cover essential living expenses while they recover and work towards returning to their jobs. It's important to note that temporary disability benefits are usually provided for a limited duration, and they cease once the employee reaches maximum medical improvement or is deemed fit to return to work, even if they have not fully recovered.

A. Compensation for Lost Wages

Temporary disability benefits are designed to provide financial support when the injured employee is unable to work due to the work injury or illness. These benefits often amount to a percentage of the employee's regular wages and are crucial for maintaining financial stability during recovery.

B. Partial and Total Disability

Temporary disability benefits can be classified into two main categories: partial disability and total disability. Partial disability benefits are provided when the injured employee can work in a limited capacity, while total disability benefits are applicable when the employee is unable to work at all.

How Are Temporary Disability Benefits Calculated?

The amount of temporary disability benefits is typically calculated as a percentage of the employee's pre-injury wages. This percentage is often determined by state laws or workers' compensation regulations and can vary depending on factors such as the severity of the injury, the employee's occupation, and the jurisdiction's rules. For this reason, it's important to speak with a personal injury attorney about your workers' comp claim and disability benefits.

3. Permanent Disability Benefits

A. Long-Term Impairment Compensation

In cases where the work-related injury or illness results in permanent impairment, workers' compensation can provide permanent disability benefits. The severity of the impairment, as determined by medical evaluations, influences the amount of compensation.

B. Scheduled and Non-Scheduled Awards

Permanent disability benefits can be categorized into scheduled and non-scheduled awards. Scheduled awards are applicable for specific injuries, such as the loss of a limb, while non-scheduled awards address impairments that are not specified in the schedule.

4. Vocational Rehabilitation

A. Training for New Job Skills

When injuries prevent employees from returning to their previous roles, workers' compensation can cover the costs of vocational rehabilitation. This includes training for new job skills, education programs, and job placement assistance to facilitate a smooth transition to a different line of work.

B. Job Placement Assistance

Vocational rehabilitation programs often offer job placement services, helping injured workers find suitable employment opportunities based on their capabilities and skills.

C. Counseling and Guidance

The emotional toll of a work-related injury can be substantial. Vocational rehabilitation can also encompass counseling and guidance to help individuals cope with the psychological and emotional challenges they may face.

5. Death Benefits: Compensation to Dependents

In tragic cases where a work-related injury or illness leads to the death of an employee, workers' compensation extends to dependents. Death benefits can include financial compensation for dependents, funeral expenses, and burial costs. If you're involved in a workers' comp claim that involves a death, contact a personal injury attorney immediately.

6. Travel Expenses

A. Reimbursement for Travel

Workers' compensation often covers the expenses associated with travel to and from medical appointments, ensuring that injured employees can access necessary medical care without financial strain.

B. Costs for Medical Care Access

In cases where the employee must travel to receive specialized medical treatment, workers' compensation can also encompass costs related to transportation, accommodation, and meals.

C. Temporary Lodging Expenses

In cases where medical treatment requires travel and temporary lodging, workers' compensation can include reimbursement for lodging expenses incurred during the course of medical care.

Some jurisdictions allow the recovery of attorney's fees incurred during the workers' comp claim process. This provision ensures that injured employees can seek legal representation without worrying about additional financial burdens.

8. Other Expenses

Workers' compensation can cover other reasonable and necessary expenses directly related to the work-related injury or illness. This might include durable medical equipment, assistive devices, and home modifications to accommodate new physical limitations.

9. Psychological and Emotional Distress

Some workers' compensation programs recognize the impact of work-related trauma on an individual's mental health. Therefore, coverage may extend to mental health services aimed at addressing psychological and emotional distress stemming from the incident.

10. Job Protection

Workers' compensation benefits can include job protection measures, ensuring that employees are reinstated to their job positions once they have recovered and are deemed fit for work.

11. Long-Term Care

In cases where injuries or illnesses lead to long-term medical care needs, workers' compensation may cover the costs associated with continued medical treatments, therapies, and assistive devices.

12. Third-Party Claims

If a third party's negligence contributed to the work-related injury or illness, workers' compensation benefits might cover claims filed against these third parties to seek additional compensation.

When to Consult an Attorney for Your Workers' Comp Claim

Consulting an attorney for your workers' compensation claim is advisable when navigating complex or contentious situations. If your workers' comp claim has been denied, partially approved, or if you encounter challenges in accessing the full benefits you deserve, seeking legal counsel can be essential. A personal injury attorney can review your worker's comp claim and help you file an appeal if your workers' comp medical costs aren't fully covered.

Personal injury attorneys with expertise in workers' compensation law can guide you through the appeals process, help gather necessary evidence, and advocate for your rights during hearings. Additionally, if your injuries are severe, involve long-term disability, or if you face resistance from your employer or insurance company, an attorney can ensure that you understand your rights, negotiate on your behalf, and ultimately enhance your chances of obtaining the appropriate compensation for medical expenses, lost wages, and other related costs.

Final Word: Workers' Comp Claim Reimbursement

Workers' compensation serves as a vital safety net, offering financial support and reimbursement for a wide range of medical expenses incurred due to work-related injuries or illnesses. Understanding the diverse categories of expenses covered under workers' compensation medical claims is essential for both employees and employers.

By comprehending the scope of reimbursement, injured workers can better navigate the recovery process and ensure they receive the care they need without undue financial strain. For employers, a clear grasp of the workers' compensation benefits available to their employees helps foster a safer and more supportive work environment, emphasizing the importance of employee well-being.

If you need to speak to a personal injury attorney about your workers' comp claim, contact our workers' compensation lawyers at  910-295-2525 for a free 30-minute consultation.

Disclaimer: The information seen on this website, including the article above, is not legal advice or legal counsel. If you wish to speak to a personal injury lawyer, contact our North Carolina personal injury attorneys directly using our online form or by calling  910-295-2525. While our law firm is located in North Carolina, our attorneys have tried personal injury cases and work with clients across the country, from RaleighFayettevillePinehurst, and Sanford, to Virginia, Illinois, Oregon, and California to Florida. Call our experienced worker's compensation attorneys today.

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