There are two main categories of workers’ compensation benefits: (1) medical benefits, and (2) wage loss benefits.
With respect to medical benefits, your employer’s insurance company must pay for all “authorized” medical treatment that is medically necessary and causally related (51% or more) to the work injury. “Authorized” means that, in most circumstances, your employer’s insurance company gets to choose your doctors. If you receive unauthorized medical treatment, you may be responsible for the bills.
Regarding wage loss benefits, there are four main categories of benefits: (1) Temporary Partial Disability benefits, (2) Temporary Total Disability benefits, (3) Permanent Impairment benefits, and (4) Permanent Total Disability Benefits.
1. Temporary Partial Disability Benefits: If the physician authorized by the workers’ compensation insurance carrier assigns physical restrictions or limitations (often commonly referred to as “light duty” or “modified duty”) prior to the date of maximum medical improvement and your employer cannot accommodate the restrictions, you are entitled to Temporary Partial Disability benefits. You could also be entitled to Temporary Partial Disability benefits if your employer accommodates your physical restrictions and your income falls below 80% of your pre-injury average weekly wages. If your employer offers a light-duty assignment within your restrictions and you refuse the work, the employer may deny temporary partial disability benefits. If this happens, you have to prove that your refusal is justifiable.
2. Temporary Total Disability Benefits: If the physician authorized by the workers’ compensation insurance carrier takes you out of work entirely (i.e., no work status) prior to the date of maximum medical improvement, you are entitled to Temporary Total Disability benefits equal to 66 2/3 percent of your pre-injury average weekly wage.
3. Permanent Impairment Benefits: When you reach maximum medical improvement, the authorized treating physician will determine whether you have a permanent injury based on a uniform permanent impairment rating schedule. For each percentage impairment point you are entitled to the following:
a. 2 weeks of impairment benefits for each percentage point between 1% and 10%.
b. 3 weeks of impairment benefits for each percentage point between 11% and 15%.
c. 4 weeks of impairment benefits for each percentage point between 16% and 20%.
d. 6 weeks of impairment benefits for each percentage point from 21% and higher.
The weekly amount of permanent impairment benefits is 75% of the amount of Temporary Total Disability Benefits. However, if you return to work and earn an income equal to or in excess of your pre-injury average weekly wage, the permanent impairment benefits will be reduced by 50%.
4. Permanent Total Disability Benefits: In certain circumstances after you reach maximum medical improvement, you may be permanently and totally disabled. If so, you are entitled to compensation equal to 66 2/3 percent of your pre-injury average weekly wage. Generally, entitlement to Permanent Total Disability Benefits ceases when you reach age 75. If the accident occurred on or after you reached age 70, Permanent Total Benefits are payable for 5 years.
Certain catastrophic injuries give rise to a presumption that you are permanently and totally disabled:
a. Spinal cord injury involving severe paralysis of an arm, a leg, or the trunk;
b. Amputation of an arm, a hand, a foot, or a leg involving the effective loss of use of that appendage;
c. Severe brain or closed-head injury as evidenced by:
i. Severe sensory or motor disturbances;
ii. Severe communication disturbances;
iii. Severe complex integrated disturbances of cerebral function;
iv. Severe episodic neurological disorders; or
v. Other severe brain and closed-head injury conditions at least as severe in nature as any condition provided in sub-subparagraphs i.-iv.;
d. Second-degree or third-degree burns of 25 percent or more of the total body surface or third-degree burns of 5 percent or more to the face and hands; or
e. Total or industrial blindness.
In all other cases, in order to establish permanent total disability, you must establish that you are not able to engage in at least sedentary employment, within a 50-mile radius of your residence, due to your physical limitations. There are three ways to meet this standard:
a. permanent medical incapacity to engage in at least sedentary employment, within a 50-mile radius of your residence, due to physical limitation;
b. permanent work-related physical restrictions coupled with an exhaustive but unsuccessful job search; or
c. permanent work-related physical restrictions that, while not alone totally disabling, preclude you from engaging in at least sedentary employment when combined with vocational factors.