Workers’ Compensation FAQ
- When must I report a work injury?
- Can I see my own doctor?
- How long does the insurance company have to decide whether to pay my claim?
- If the insurance company decides to pay, when will I start receiving benefits?
- What happens if the insurance company denies my claim?
- What is mediation?
- How long does it take to get a hearing?
- What happens at the hearing?
- How is my benefit amount calculated?
- Under what circumstances can the insurance company discontinue or reduce my benefits?
- Am I eligible for unemployment?
- Am I eligible for disability?
- What types of medical treatment are covered by workers’ comp?
- What is an IME?
- Can my employer fire me for making a claim?
- How long does my employer have to hold my job while I am out on workers’ comp?
- Can my employer cancel my health insurance while I am out on workers’ comp?
- My employer is ignoring my restrictions. What do I do?
- My employer cannot accommodate my restrictions. Do I have to look for other work?
- How long can I receive weekly benefits?
- What do I owe for attorneys’ fees?
- The insurance company offered me a settlement. How do I know if it’s fair?
If you are injured on or after January 1, 2013 you have 30 days to report a work injury to your employer. However, certain injuries, like those that occur as the result of repetitive stress or overuse, develop gradually, with symptoms worsening over time. If your work duties are causing you pain, report it, even if it is not keeping you from working - - yet. Make sure you tell your employer that your injury is caused by your work duties. You have the right to see a doctor. You also have the right to ask for modifications to your duties or worksite. If you are losing time from work, tell your employer you are seeking compensation. Your employer should fill out an injury report and notify the insurance company of your claim. Failure to report a work injury within 30 days of the date you knew about it, or should have known about it, will permanently bar your claim.2. Can I see my own doctor?
Yes. However, for the first 10 days after an injury, your employer may also require you to see the company doctor, also known as the “10 day provider.” After 10 days, you are no longer required to see the company doctor.3. How long does the insurance company have to decide whether to pay my claim?
The insurance company has 14 days from the date it is notified to pay or deny your claim. If they pay, they must file a Memorandum of Payment which states the amount you will receive. If they deny, they must file a Notice of Controversy which states the reason for the denial. Full denial means the insurance company is denying payment of both lost time and medical. Partial denial means the insurance company is paying one but not the other.4. If the insurance company decides to pay, when will I start receiving benefits?
After 7 days of missed work due to your injury, you are entitled to receive weekly compensation benefits beginning on the 8th day. If you miss more than 14 days of work, you will then receive payment retroactive to the original date of injury.5. What happens if the insurance company denies my claim?
The insurance company is required to file the Notice of Controversy with the Workers’ Compensation Board. Once the Workers’ Compensation Board receives the Notice of Controversy, the troubleshooter will send you a letter asking you to contact the Board if you intend to pursue your claim further. The troubleshooter will then refer your claim to mediation, which is the next step in the process.6. What is mediation?
Mediation is a mandatory step in the claim process. The parties meet to discuss the claim and any defenses and try to reach an agreement with the help of the mediator. The mediator is not a hearing officer and cannot order the insurance company to pay benefits. Rather, the mediator can only help the parties to reach agreement on their own. If mediation is unsuccessful, the mediator will forward your claim onto formal hearing.7. How long does it take to get a hearing?
It depends. The Workers’ Compensation Board has a large number of cases and it can take several months. If you are totally unable to work as determined by a doctor, or if your claim involves the right to receive necessary medical treatment, you can request an expedited proceeding, but it can still take some time.8. What happens at the hearing?
You will testify under oath before a hearing officer regarding the circumstances of your work injury. Your employer may bring witnesses to testify as well. The doctors’ reports are admitted into evidence, and the doctors may also testify by deposition. The hearing officer will set a date for the lawyers to submit “position papers” and will issue a decision sometime after that.9. How is my benefit amount calculated?
For injuries occurring on or after January 1, 2013, your total benefit is 2/3 of your gross average weekly wage, but not more than the maximum benefit level which is $728.63. For injuries occurring prior to January 1, 2013, your total benefit is 80% of your net average weekly wage, but not more than the maximum benefit level. For most workers, average weekly wage is calculated by averaging your earnings over the 52 weeks preceding the injury.10. Under what circumstances can the insurance company discontinue or reduce my benefits?
In most cases, the insurance company accepts your claim voluntarily and pays benefits “without prejudice.” Under these circumstances, it can discontinue or reduce benefits with a “21 day notice.” However, it must have good cause for doing so. Good cause can include a doctor releasing you back to work or stating that your injury is not work related. It can also include your refusing a reasonable offer of light duty or a labor market survey showing there is light duty available in your area. Finally, it can include surveillance of you engaging in activities (in the real world or on Facebook) which are inconsistent with your claimed injury. If you receive a 21 day notice, call Maine Employee Rights Group right away. We can file an emergency petition asking the Board to reinstate your benefits pending a hearing. If the insurance company is paying benefits pursuant to a Board order, it must petition the Board for a hearing and prove there has been a change in circumstances in order to discontinue or reduce your benefits.11. Am I eligible for unemployment?
If you are medically unable to work, you are not eligible for unemployment compensation. If you apply and receive unemployment, your employer is entitled to offset your workers’ compensation benefits by the amount of your unemployment. If your employer offers short term or long term disability as part of your compensation package, it is also entitled to offset your workers’ compensation benefits by the amount of that benefit.12. Am I eligible for disability?
Some employers offer private disability insurance as part of your compensation package. Your eligibility for benefits depends on whether you meet the requirements of the plan. There may be an exclusion for work related injuries. If your injury has not been adjudicated as work related, the disability insurer may be required to pay benefits on a provisional basis, and may have a right to reimbursement later. Social Security Disability Insurance (SSDI) is through the federal government. Your eligibility for benefits depends on whether you meet the government’s definition of “disabled” which includes a multi-step analysis.13. What types of medical treatment are covered by workers’ comp?
The Workers’ Compensation Act covers all reasonable and proper medical, surgical, and hospital services, nursing, medicines, and mechanical aids, as needed, as well as treatment by a specialist, including a chiropractor. Acupuncture, massage therapy, and other nontraditional therapies are sometimes covered by agreement.14. What is an IME?
An IME is an insurance medical exam. The Workers’ Compensation Act allows the insurance company to send you to its doctor for a one-time evaluation and report. The Act allows the insurance company to schedule an IME at any reasonable time during your claim, whether they are paying benefits or not. You have the right to know what questions the insurance company is asking the doctor to answer. You are also entitled to a have a doctor of your own choice present with you at the exam, whose costs are paid by the insurance company. Maine Employee Rights Group works with a team of doctors who attend IME’s with our clients.15. Can my employer fire me for making a claim?
The Workers’ Compensation Act contains an anti-discrimination provision that makes it unlawful for your employer to fire you because you asserted your rights under the Act. These cases are complex and require skilled legal representation to prove the discrimination. If you win, you will receive your full pay (as opposed to 2/3 or 80%) and your attorneys’ fees will be paid by the employer or insurance company.16. How long does my employer have to hold my job while I am out on workers’ comp?
It depends. The Workers’ Compensation Act does not contain a specific provision requiring your employer to hold your job for any length of time. However, it does contain a provision under which you can request reinstatement to your job or to one which you are physically capable of performing, provided you make the request within a certain time frame. Depending on the size of your employer and how long you have worked there, you may be entitled to job protection under the Family Medical Leave Act (12 weeks per year) or its Maine counterpart (10 weeks every 2 years).17. Can my employer cancel my health insurance while I am out on workers’ comp?
It depends. If you are covered under the FMLA or its Maine counterpart, your employer is required to maintain your health insurance during the period of job-protected leave, however you must continue to pay your portion of the premium.18. My employer is ignoring my restrictions. What do I do?
You have the right to refuse any assignment that exceeds your restrictions. Keep a copy of your restrictions with you at all times. If your employer persists, talk to your doctor. Ask your employer to give you a job description that you can take to your doctor to review.19. My employer cannot accommodate my restrictions. Do I have to look for other work?
Yes. Under the “work search rule,” as long as you have partial work capacity, you must look for work and prove that it is unavailable in order to claim total benefits. It is very important to document your work search. The hearing officer will consider the number of jobs you apply for; whether the jobs you apply for are suitable given your injury, age, education and experience; and whether you are making good use of the newspaper, internet, and Career Center. If the hearing officer is satisfied that you have proven work is unavailable, he will award total benefits.20. How long can I receive weekly benefits?
It depends on when you were injured and the degree to which your injury limits your ability to work and earn pay. If you are totally medically disabled under Section 212 of the Act, you are entitled to receive benefits for as long as your disability lasts. If you are partially disabled under Section 213 of the Act, your entitlement is subject to a 520 week (10 year) cap, with the possibility of extension for financial hardship, unless your permanent impairment exceeds a certain threshold as determined by a doctor. There is no durational limit on medical treatment.21. What do I owe for attorneys’ fees?
Attorneys’ fees are set forth in Section 325 of the statute. At Maine Employee Rights Group, we do not charge a fee unless we win money for you. In that case, our fee is 30% of accrued benefits (including back pay and ongoing weekly) and 10% of the first $50,000 in settlement, 9% of the next $10,000 and so on according to the statute.22. The insurance company offered me a settlement. How do I know if it’s fair?
Call Maine Employee Rights Group. We know how to value your claim and make sure you are getting the compensation you deserve.