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Workers' Compensation

Exactly what is workers' compensation?
Workers' compensation is a benefit program that provides medical and income benefits, and in certain circumstances, rehabilitation to an employee injured on the job. This program may also provide benefits to an employee’s dependents if death results from an on-the-job injury.

When does coverage begin?
Coverage begins under the workers' compensation program on an employee’s first day on the job.

What is considered an on-the-job injury?
Any injury or illness arising out of and in the course of employment is by definition an on-the-job injury. Claims for injury occurring during breaks, lunch or personal activity may not be compensable.

What should supervisors do when an employee is injured?
Make sure the injured employee is given the opportunity to contact the number listed for the Managed Care Organization on the panel in order to choose a physician from the MCO Provider Network and is explained the Employee’s Bill of Rights as provided by law. Make sure the injury is reported in accordance with company procedures and the Act. Failure to follow these procedures could delay or jeopardize the employee’s claim, delay the employee’s recovery and return to work, result in employer penalties, and/or allow the employee to choose a non-panel physician.

Are on-the-job accidents or injuries investigated?
Yes, your company’s insurance carrier or claims administrator, and sometimes OSHA, may investigate on-the-job accidents or injuries. Investigations are necessary to determine how an injury occurred, if the injury is compensable, and find ways to prevent similar injuries from happening again.

Are employee misconduct claims resulting in on-the-job injuries covered?
Generally, workers' compensation law does not provide benefits for an injury or accident resulting from an employee's willful misconduct.

What if the supervisor is concerned about safety records?
Any safety program that encourages employees to be safety conscious and prevent accidents is recommended and supported by the Board. Safety records should not, however, interfere with or take precedence over the prompt and proper reporting of employee injuries and accidents.

If an employee goes to his or her personal physician for treatment for an on-the-job injury, is the employer responsbile for paying the medical costs?
Generally, no. The law requires the company to post in a conspicuous place at each work location a list of at least six physicians who are authorized to treat on-the-job injuries, at no cost to the employee. When an on-the-job injury occurs, the injured employee must contact the number given for the MCO to select a physician from the Provider Network for treatment. If the employee is dissatisfied with the first selection, the employee is allowed one change to another physician from the Provider Network.

What must supervisors do if emergency treatment is needed?
If a true emergency situation exists, get temporary medical care from the nearest emergency location available. Once the emergency is over, however, the injured employee must return to a physician from the Provider Network for continued treatment. The employer may not be responsible for coverage of unauthorized treatment once the emergency is over.

Does the employee pay a portion of the medical charges?
No. Physician's bills and other medical bills are fully covered if a physician on the Posted Panel of Physicians treats the employee. All medical charges are paid according to the Medical Fee Schedule. Therefore, if providers bill above the fee schedule limits, the excess charges are not required to be paid by the employer or the employee. Employers who are billed for excess charges should simply notify the insurance carrier or claims administrator. Should the employee choose, however, to go to a physician that is not on the Posted Panel of Physicians, this may be considered unauthorized treatment and the company may not be required to pay for the charges. The claims administrator/workers’ compensation carrier coordinates all on-the-job injuries with the health insurance carrier.

Must the employee submit to medical examinations at reasonable times?
As long as the employee is receiving compensation, he is required to be examined by the authorized treating physician at reasonable times. If the employee refuses to do so, his right to compensation shall be suspended until such refusal or objection ceases.

Does the employee get reimbursed for prescription drugs, parking, meals, prescribed medical supplies, and travel expenses?
Prescription drugs are covered by the Workers’ Compensation Act. The employee should check with the employer to determine if any special arrangements have been made for direct payment of prescription charges. If not, the employee should pay for the prescriptions and submit the bill for reimbursement to the insurance carrier or claims administrator.

Under the Act, employees are entitled to reimbursement for parking, mileage, and some meals. Requests for mileage reimbursement should show exact miles and locations, and must be submitted within one year of the date of service.. The Board sets the mileage reimbursement rate. Supervisors should discuss other expenses with the claims administrator or workers’ compensation carrier. Reimbursement payments must be paid within thirty (30) days or they may be subject to a late payment penalty.

What happens if an employee is unable to work because of the on-the-job injury?
An injured employee is entitled to receive weekly temporary total disability benefits if the employee misses more than seven days from work. The first check should be mailed within 21 days after the first day the employee misses work. If the employee is out more than 21 consecutive days due to his or her injury, the employee will be paid for the first seven days. The employee will receive two-thirds of his/her average weekly wage, but not more than the maximum rate provided by the Act at the time of injury.

How long will the injured employee receive weekly temporary total disability benefits?
Effective July 1, 1992, for non-catastrophic injuries, the injured employee is eligible for weekly income benefits for as long as     he or she is totally disabled, up to a maximum of 400 weeks from the date of injury. For catastrophic injuries, the employee is entitled to receive weekly income benefits for as long as he/she is totally disabled.

What happens to an injured employee’s benefits if the physician authorizes a light-duty return to work?
Every effort should be made to return the injured employee to work in a suitable light-duty job. If no light-duty job is available for the employee, the employee continues to be entitled to disability benefits. If the employee remains out of work in a light-duty status for 52 consecutive weeks or a maximum of 78 aggregate weeks, the weekly income benefit can be reduced automatically by law from the temporary total disability rate to the temporary partial disability rate. Also, if the employee has been released to light duty and a light-duty job is available, most employers will expect the employee to return to work. A refusal to return to work in this situation could result in suspension of workers' compensation benefits. The law allows a 15-workday “grace period” so that the employee may attempt to perform a light-duty job without fear of losing benefits.

What if the employee can no longer do his or her regular job and must take a lower paying job once released to return to work?
The injured employee may be eligible to receive temporary partial disability benefits based on a reduction in earnings. The employee will receive two-thirds of the difference between the pre-injury and post-injury average weekly rates of pay not to exceed the rate provided by the Workers' Compensation Act at the time of injury. These benefits will terminate when the employee’s average weekly wage is the same or greater than the pre-injury wage or upon a maximum payment of 350 weeks from the date of injury.

What happens if the employee’s on-the-job injury causes permanent partial disability?
The supervisor should be aware of available modified or alternative work and is responsible for communicating with the employee regarding modified or alternative work. This is important as the availability of alternative work affects entitlement to workers’ compensation indemnity benefits.

Will the injured employee’s dependents receive benefits if death occurs as the result of an on-the-job injury?
Yes. Death benefits are payable to eligible dependents (i.e.: dependent spouse, minor children) of an employee whose on-the-job injuries resulted in death. The Act provides the employer shall pay the dependents that are wholly dependent on the deceased employee’s earnings for support at the time of the injury. Dependents are entitled to a weekly compensation equal to two-thirds of the deceased employee’s average weekly wage (not to exceed the maximum rate provided by the Act at the time of the injury.) The number of dependents does not affect the benefit amount. When the surviving spouse is the sole dependent of a deceased employee, depending on date of injury, total benefits are limited to a maximum of $100,000 (effective July 1, 1992) or $125,000 (effective July 1, 2000). The dependency of a spouse and of a partial dependent shall terminate at age 65 or after payment of 400 weeks of benefits, whichever provides greater benefits. A child’s benefit will terminate at the age of 18 unless the child is physically or mentally incapable of earning a livelihood, or at age 22 if he or she is a full-time student enrolled in a post-secondary school. Burial expenses will be paid up to a maximum amount as provided by the Act. See O.C.G.A. §34-9-265.

What happens if an employee re-injures a pre-existing condition or injury?
The workers’ compensation law limits the extent to which an aggravation of a pre-existing condition or injury is compensable. An aggravation of a pre-existing condition will only be found to be compensable while the aggravation is the cause of the disability. Once the aggravation resolves and the injured employee returns to the pre-injury condition, the claim will no longer be compensable.

What if the injured employee's claim is denied by workers' compensation?
If the injured employee’s claim is denied, the employee should be notified of the reasons for the denial by receipt of a Form WC-1, which is filed with the Board by the claims administrator. The employee has the right to request a hearing before the State Board of Workers' Compensation if he or she disagrees with the denial of the claim.