What Are the Requirements for Workers Compensation Eligibility?

When you sustain an injury while on the job, you are usually eligible for workers’ compensation benefits. This coverage includes reimbursement for your medical expenses as well as any lost wages. 

You receive these payments, regardless of who was at fault during the accident (though there are some exceptions). In return for these guaranteed benefits, you forfeit the right to sue your employer for any other damages.

Workers’ compensation benefits are beneficial to employees because they guarantee insurance coverage in the event of a work-related injury or illness. However, you need to meet specific requirements and file your claim as soon as possible to meet your employer’s and state’s reporting rules.

There are requirements you need to meet to ensure workers’ comp eligibility. Failure to meet these requirements could prevent you from receiving the benefits. Here is what you need to consider: 

  1. Your employer must have workers’ compensation.
  2. You must be an eligible employee.
  3. Your injury or illness must be related to work.
  4. You have to meet reporting requirements.
  5. You must attend all appointments and meetings.

Here is a closer look at each of these eligibility requirements.

1. Your Employer Must Have Workers’ Compensation

Generally, most employers are required to have workers’ compensation insurance. While state laws vary, this requirement for workers’ compensation insurance can depend on the number of employees, the type of business, and the type of work done by employees. Most states require all employers to have workers’ comp coverage, but some may require a minimum of three direct employees before a company must purchase coverage.

Some states have different rules for certain kinds of jobs, such as construction and agriculture. Others allow certain businesses, such as non-profits, to opt-out of coverage. 

There are also employers who, despite not being required to purchase workers’ compensation coverage, do so nevertheless. States usually allow such employers to opt into the workers’ comp system. In return, they are exempt from lawsuits by employees.

The federal government has its own system for workers’ compensation. If you are a federal employee, you should look into that system instead of your state’s laws. There are also separate worker’s compensation rules for railroad employees, miners, and maritime workers.

Before filing a claim, be sure to check whether your employer has workers’ compensation coverage, or whether they fall into any exempt categories. The U.S. Department of Labor should have useful information on which agency oversees workers’ compensation in your state or area of work.

2. You Must Be an Eligible Employee

While all employees are workers, not all workers are employees. There are some exemptions to worker’s compensation rules. For example, if you are a consultant, independent contractor, or freelancer, then you are not eligible for workers’ compensation benefits for your clients. 

This is a thorny area, and there can be disputes over who is eligible for workers’ comp. 

Take an Uber or Lyft driver, for instance: In some states, they are employees, while in others, such as Texas, they are considered independent contractors

On the other hand, employers often misclassify otherwise bona fide employees as independent contractors to get out of paying workers’ compensation premiums and payroll taxes. Therefore, you should ensure that your contract lists you as an employee. 

If you are an independent contractor, you may still qualify as an employee. If your employer requires you to show up at work for a set number of hours every day, for example, or if you do most of your work for that employer, you may qualify as an employee. However, having your status directly mentioned in a contract is essential because an insurer and company will often take cases involving independent contractors to court, which can be a drawn-out process. 

3. Your Injury or Illness Must Be Related to Work

If your employer has workers’ compensation coverage and you are a bona fide employee, you must still meet specific requirements to receive benefits. First of all, your injury or illness must be related to work. 

In general, if you become ill or injured doing something for the benefit of your employer, then you are legally on-the-job. Examples of this might include:

  • Straining your back while loading boxes at work.
  • Becoming ill due to exposure to hazardous substances at the worksite.
  • Even breaking your leg on an official company retreat while skiing.

There are exceptions to these rules which include:

  • You purposely self-inflict a wound.
  • Your injuries were a result of fighting or playing around.
  • Your injuries occurred while you were under the influence of alcohol or drugs.
  • Your injuries occurred while you were committing a crime.
  • Your injuries happened as the result of a violation of company policy.

As long as you or your legal representative can prove a link between standard work activities and your injury, it counts as “work-related.” In more complex cases, however, having a specialized worker’s comp lawyer can be beneficial.

4. You Have to Meet Reporting Requirements

You need to report the work injury in a timely fashion to avoid having your claim denied. Each state has its own rules concerning this step. First, you need to make your employer aware of your injury or illness. In some states, such as South Dakota, you must do this within three days. In others, such as New Hampshire, you have up to two years to inform your employer. Most states give you up to 30 days to begin the process.

Once you have made your employer aware of the injury or illness, you should file your claim in a timely fashion. Again, deadlines differ by state. Most of them require you to file the claim within 12 months, though many others may give you two years.

Find out what your state’s laws are concerning reporting requirements and be proactive about meeting those conditions. Your employer and their insurer may also have additional reporting requirements, which are almost always stricter than state laws, and may lead to them refusing to provide you with a claim form. It is best to make sure you meet them to ensure the fastest possible disbursement of funds.

5. You Must Attend All Appointments and Meetings

Meeting all the requirements for worker’s comp will likely get you an award or settlement. However, there is one last stipulation. Both employers and insurers are always on the lookout for fraudulent claimants. If your award includes medical and legal benefits, but you keep rescheduling or missing appointments, you may not continue receiving payouts. 

The insurer or employer can claim that you’re being medically non-compliant. Some insurance companies may even hire investigators. These observers will check on claimants who skip medical appointments to see if they are active in other ways, suggesting they are not in as much pain as they claim. If they can prove this, they can stop payments

Unlike personal injury settlements, which are usually one-time payments, workers’ comp insurance benefits are recurring, so proving you are making a good-faith effort in recovering is part of the process. 

Work With An Experienced Local Lawyer

Hire an experienced workers’ compensation attorney as soon as the insurer or your employer shows signs of making your recovery difficult. If your injury involves an occupational illness or a cumulative injury, you may also benefit from a knowledgeable lawyer. An attorney will fight on your behalf for your rights to benefits as well as for the maximum amount of compensation. Retain the help you need at this difficult time in your life.

Submit a request online or call us today at (866) 345-6784 to get in touch with an attorney in your area!

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