What is Workers' Compensation?
- Workers' Compensation is a system that provides medical benefits and compensation to individuals injured in the course and scope of their employment. For a claim to be compensable an injury or occupational disease must occur in the “course and scope” of an employee's employment” and “arise out of the employment.” See C.R.S. §8-41-301(1)(b).
- Workers' compensation is a type of insurance coverage that employers must provide for their employees. For employees who are injured on the job or develop occupational diseases, this insurance pays for medical expenses and partial wage replacement during periods of temporary disability. It may also provide permanent impairment benefits for those who qualify. The cost of workers' compensation insurance is paid entirely by the employer and may not be deducted from an employee's wages.
- Workers' compensation benefits are based on the date of injury. Since the laws change through the years, there may be different benefits depending on when you were injured. If you are injured on the job, you should know that papers need to be filed correctly and within the right number of days. You must follow all rules and procedures or you might not get all the benefits you may be entitled to receive.
- The Colorado Workers' Compensation System enables injured workers to obtain compensation for work injuries without having to prove negligence against their employers. In exchange for this, the workers gave up the right to sue their employer at common law for pain and suffering, or damages.
- An injured worker must report an injury to the employer immediately. If the injury is not life or limb-threatening, the injured worker selects a doctor from medical providers that have been designated by the employer to treat the injuries.
- The physician selected by the injured worker becomes the authorized treating physician for purposes of this injury. Unless physically or mentally unable to do so, the injured worker must also notify the employer of the injury in writing within 4 working days of the injury.
- Designating a medical provider: In Colorado, the employer or insurance company has the right in the first instance to select the physician who attends an injured employee. This becomes the designated medical provider. The statute requires with some exceptions, that a list of at least four physicians, corporate medical providers, or a combination of both, where available, be provided by the employer so as to afford the injured employee the opportunity to select a treating physician. At least one of the designated providers must be at a distinct location from the other three and have distinct ownership. This provider may be changed by making a written request within 90 days.
- When selecting the designated physician it is extremely important to assure that you are furnishing the best medical care possible. Quality and appropriate medical care is important to maximize your recovery and benefits.
- The employer notifies its insurance company (insurer) of the injury within 10 days of having been notified or having actual knowledge of the incident. This often takes the form of an Employer's First Report of Injury. Unless the claim is denied, related medical benefits are paid.
- If the employee loses time from work in excess of 3 days (or 3 shifts); OR there is likely to be permanent impairment, OR the employer disputes the claim.
- The Insurer must file an Employer's First Report of Injury with the Division of Workers' Compensation. Within 20 days of notice of the injury, the insurer must state a position as to whether it accepts liability for payment of benefits (filing an Admission of Liability form), or denies liability for payment of benefits (a Notice of Contest form).
- If the claim is admitted, authorized medical benefits will be paid in addition to wage replacement for lost time from work (beginning on the fourth full day of lost time, if the total amount of time does not exceed 2 weeks; or on the first full day of lost time from work if the loss exceeds two weeks.)
- A “General Admission of Liability is a document issued which is proof you were injured on the job. The General Admission allows you to receive all legally required Workers' Compensation benefits including medical benefits and temporary total disability payments.
- The General Admission does not automatically mean you will receive the correct temporary disability payment or the appropriate medical care. An attorney should review the General Admission to ensure you are receiving all the medical benefits owed to you.
- Your employer's workers' compensation insurer can reduce your benefits by 50 percent if your injuries were the result of a safety rule violation. They can do this without a hearing and it can impact many of the workers' compensation benefits you are entitled to receive. C.R.S 8-42-112(1)(b), permits a fifty percent reduction in compensation when an injury "results from the employee's willful failure to obey any reasonable safety rule adopted by the employer for the safety of the employee." In order to impose the reduction of compensation, it is not enough for the employer to demonstrate that the claimant failed to obey safety rule. It is also necessary to show that there was a "willful" violation of the rule.
- The insurer will issue a Final Admission of Liability when all issues have been addressed, including temporary disability benefits, permanent impairment, disfigurement, and medical benefits. A final admission of liability is used by an insurance carrier to close a workers' compensation case. If you have received a final admission of liability, you need to act on it right away. Do not ignore the final admission. If you don't do something within 30 days, the case will close.
The Flow of an Undisputed Worker's Compensation Claim:
A Workers' Compensation Claim Process Flowchart documenting procedures and details for an uncontested claim is as follows:
SUMMARY OF BENEFITS TO INJURED WORKERS:
- Medical Treatment: When you are hurt on the job, the employer has the right to select a physician who treats you. The selection of the physician is extremely important to assure you are getting the best medical care possible. Your employer is required to provide medical care that is reasonable, necessary, and related to your workplace injury. You cannot be charged for this care. Medical care will be provided until you reach Maximum Medical Improvement (MMI). Medical maintenance care is available after you reach MMI if it is necessary to maintain your medical condition.
- Wage losses: If you miss more than three days from work you should be entitled to wage loss benefits. When you are totally unable to earn wages, your employer must provide Temporary Total Disability benefits (TTD). Generally, this amount will be 2/3 of your average weekly wage (AWW). If you are able to return to work on modified duty with reduced hours or wages you are entitled to Temporary Partial Disability (TPD).
- Calculation of Average Weekly Wage (AWW): C.R. S. 8-42-102 provides the basis upon which to compute the average weekly wage. In general, a monthly wage is multiplied times twelve and divided by fifty-two, and an hourly rate is multiplied by not less than eight hours or, less than five days. TTD and TPD payments are limited by law at and fixed maximum amount that, by law, changes every July 1st. The current maximum TTD rate is $987.84
- How long are Temporary Disability benefits Paid? Temporary benefits are paid until you are at Maximum Medical Improvement (MMI) from all of your injuries due to your work-related accident. Temporary Total Disability (TTD) payments start after you are off work for three calendar days or three shifts. You will receive Temporary Total Disability payments if the primary care physician states, in writing, that you are not to work, or imposes work restrictions that your employer cannot comply with, such as light-duty or modified work within those restrictions. Your average weekly wage can include overtime and the value of employer-paid health insurance benefits. Temporary benefits will end when you are released to work, reach maximum medical improvement, or you fail to attend the compelled medical appointment.
- Authorized Treating Physician: You may see a doctor of your choice if the employer fails to provide a list within a specific time from the date of your injury. Additionally, you have a right to change doctors, however, strict deadlines apply.
- Permanent Partial Disability (PPD): Permanent Partial Disability is a permanent loss of function to a body part/system. If you do not fully recover from your injury, your doctor will determine the amount of permanent impairment and award a percentage. The percentage will correlate with your financial award. Two types of impairment exist:
- Scheduled Impairment: Means loss of function affecting the toes, feet, legs, fingers, hands, arms, eyes, vision or hearing, compensated based on a schedule of values related to each body part.
- Whole Person Impairment: Means loss of function affecting body parts not listed on the schedule above, such as the spine, lungs, and mental function, compensated based on factors of impairment rating assigned by the doctor, age factors, a fixed factor of 400 weeks, and temporary total disability rate.
- Special note on shoulder injuries: Often times insurance carriers will admit on shoulder injuries as a scheduled vs. whole person because they will have to pay less in permanent benefits. If there are complaints into the neck and back, it is critical you notify your providers and document these complaints to assist your attorney to argue the scheduled rating should be converted to a whole person enabling your entitlement to maximum compensation.
- Permanent Total Disability (PTD): Permanent total disability means you are unable to earn any wages. Benefits for PTD are based on 2/3 the average weekly wage in effect at the time of the injury or illness and are paid for the lifetime of the injured worker.
- Mileage: You are entitled to be reimbursed mileage expenses for travel to and from authorized medical visits and to the pharmacy. You will need to itemize your travel mileage and request reimbursement in writing from the employer.
- Pharmacy: You are also entitled to prescriptions ordered by your doctor. Our attorneys can help remove the nuisance of dealing directly with the insurance carrier and coordinating mail-order delivery of your medications to your doorstep.
- Disfigurement: Disfigurement benefits are available if your injury resulted in permanent scarring, discoloration, extensive facial or body scars, burn scars, or stumps resulting from the loss of limbs. Disfigurement maximum benefit rate is presently $5,019.83 and $10,037.89 for expensive scars or stumps.
- Limitations on the amount of TTD/TPD and PPD: Caps for these types of benefits are determined by several factors. The cap depends on the impairment rating. Benefit caps do not apply until the treating physician declares you have reached MMI. For injuries occurring on or after January 1, 2006, the cap for combined temporary and permanent partial disability benefits is $75,000 if your impairment rating is 25% or less and $150,000 if your impairment rating is higher than 25%.
- Death Benefits: dependents of the deceased entitled thereto shall receive as compensation or death benefits sixty-six and two-thirds percent of the deceased employee's average weekly wages to be paid to a dependent widow or widower for life or until remarriage, in addition to burial expenses. If the decedent is a police officer, deputy sheriff, or firefighter killed in the line of duty, benefits are paid at the maximum weekly rate in effect statewide (presently $948.15). See, C.R.S 8-40-202 (1)(a)(II).
- Lump-Sum Payment: C.R.S 8-43-406 provides the opportunity to receive a lump sum payment to workers who have suffered a permanent injury. After six months have elapsed from the date of the injury, you can elect to take “all or any part” of the money owed to you in a lump sum. In order to do this, you will need to provide written notice of your request for a lump sum payment and of the amount requested. When your written request is submitted, the workers' compensation insurer must calculate the appropriate amount and file notice that the sum has been paid within 10 days. You must be informed of the method of calculating lump-sum benefits and, if the claimant is unrepresented, this calculation must be based on the present worth of partial payments and based on an assumed interest rate of 4 percent per year. Regardless of the calculation, the lump sum payments awarded may not exceed $60,000. Additionally, 8-42-123, burial expenses up to $7,000 are paid as a lump sum within 30 days of a work-related death. Further, under 8-42-120, a widow who remarries after her spouse died of a work-injury is entitled to a two-year lump sum death benefit payment upon her remarriage (less any lump sums already paid previously).
- PTSD - HOUSE BILL 17-1229 - C. R.S. § 8-41-301, as amended, allows workers to claim workers' compensation coverage for PTSD in a limited set of circumstances, based on repeated exposure to violent incidents. It also retains the statute's existing requirement that, outside the few exceptions that apply primarily to peace officers and first responders, mental impairment coverage is implicated only when an incident is outside a worker's usual experience. To qualify for mental impairment benefits under the amended statute, the worker must be diagnosed with PTSD by a licensed psychiatrist or psychologist following exposure to one or more of the following events:
- The worker is the subject of an attempt by another person to cause the worker serious bodily injury or death through the use of deadly force, and the worker reasonably believes the worker is the subject of the attempt;
- The worker visually witnesses a death, or the immediate aftermath of the death, of one or more people as a result of a violent event; or
- The worker repeatedly visually witnesses the serious bodily injury, or the immediate aftermath of the serious bodily injury, of one or more people as the result of the intentional act of another person or an accident.
- The act applies to injuries sustained on or after its effective date, July 1, 2018.