Any injury that arises out of the scope and course of employment is covered unless it was caused intentionally by the injured worker or from his/her intoxication. A covered injury can be one that was caused by a specific incident such as lifting or falling. It can also be one that doesn’t have a specific date of incident but was caused by the constant or repetitive stresses of the job. Illnesses and diseases like lung disorders, heart attacks and stress related problems that were caused by the nature of the job are also covered.
Yes. A covered injury can also be a pre-existing condition that was not work related but was aggravated by a specific injury or the constant or repetitive stresses of the job. It is typically said that an employer takes its employees as it finds them. This means that an employer is responsible to pay workers’ compensation if a pre-existing medical problem was aggravated by a work related injury.
No. Some injuries occur while traveling for an employer, while on a work related errand or while attending a mandatory work related social function. You’re covered as long as the activity that you were doing when injured was for the benefit of your employer.
In general, injuries that occur while coming to work or going home at the end of your shift are not covered. However, there are many exceptions to this rule. For example, if an employee parks his or her car in a parking area designated by the employer for employees and is injured while walking from the lot to the employer’s building, the injury is covered. There are many situations where an injury can be covered as an exception to the general rule.
Yes. You’re describing what is known as a “flow-from” injury. An injury or medical condition that results from a work related injury, like overusing an opposing body part, is considered to have flowed from the work injury and is covered by workers compensation. The insurance company has to pay all benefits for a “flow-from” injury just as if it were any other kind of work related injury.
Injured workers are entitled to weekly compensation for lost wages, payment of all medical expenses, payment for scarring and loss of use of a body part, and vocational rehabilitation. Vocational rehabilitation can include job placement assistance, on the job training and schooling.
You have to be disabled for at least 4 days to be entitled to compensation for lost wages. No compensation is payable for the first 3 days of a disability. Compensation begins on the 4th day.
Your weekly compensation rate is based on your average weekly wage which is the average of your gross earnings from all jobs where you worked before your injury, including self employed income. Your average weekly wage is then converted into a spendable base wage, based on tables published by the State of Rhode Island, which roughly represents your take home pay. Your weekly compensation rate is 75% of your spendable base wage up to a maximum that is set by the state for the year of your injury.
Injured workers who receive benefits for total disability receive an extra $15.00 per week for each dependent. A dependent is a non-working spouse, minor child or child that is a full time student in college. Total disability also pays a cost of living adjustment each year.
Total disability means the inability to do your regular job and any other kind of work. Partial disability means that you can’t do your regular job but you can do light duty types of work, regardless of whether light duty is available from your employer.
Under certain circumstances, partially disabled injured workers can be declared totally disabled. You may be awarded workers compensation benefits for total disability if your injury combined with your age, education, background, abilities and training make you unemployable. This is known as the “odd lot doctrine”.
Total disability benefits last for as long as you are totally disabled, even if that is the rest of your life. Partial disability benefits can continue for up to six years. They will continue beyond six years only if you prove to the court that your injury poses a material hindrance to your ability to get a job suitable to your limitations. At that point, your benefits will continue as if you were on total disability.
If you are receiving benefits for partial disability and you reach maximum medical improvement, the insurance company can petition the court for a 30% reduction in your weekly check. This reduction will not apply if you are working while receiving compensation. Also, the implementation of the reduction can be delayed if you can prove to the court that you are making a good faith effort at looking for a job or are participating in an approved vocational rehabilitation plan. The theory behind this law is that there is no reason why you shouldn’t be looking for a job once you are at an endpoint in treatment and know your permanent physical limitations. In fact, you have a duty to do so. If you do make a good faith effort at looking for work, then a judge has discretion to delay implementing the reduction. If you don’t look for work, you will be penalized with a 30% reduction.
Absolutely. If you earn any wages while receiving workers’ compensation, you are required to report those earnings to the insurance company. The insurance company will pay you part of the difference between what you were earning before your injury and what you are earning in your new job. Just be sure to report all of your earnings to the insurance company. Failure to report earnings is fraud and may subject you to criminal prosecution.
Yes. Your spouse will be entitled to a $15,000 payment for burial expenses. Also, your spouse will be entitled to your weekly benefits plus an additional $40.00 per week for each dependent child. If your spouse dies or remarries, the weekly benefit will be divided among your dependent children. If you die leaving no spouse, then your weekly benefit will be divided among your dependent children.
No. You are entitled to be paid for scarring or loss of use caused by an injury even if you don’t lose any time from work.
Yes. Regardless of what you may be told by your employer about company policy or by the insurance company, you have the right to choose what emergency room you want to go to and also to make the initial choice of whom you want as your doctor (emergency room visits don’t count as a first choice).
After making your initial choice of a doctor, you also have the right to be referred to a doctor of your choice who is a specialist for your type of injury. If you later want to switch to a new doctor, you have to either select a doctor on a list provided by the insurance company (called a Preferred Provider Network) or get permission from the insurance company to see a doctor that is not on the list.
If the insurance company fails to authorize treatment that is recommended by your doctor (such as physical therapy, testing, surgery, etc), you have the right to petition the Workers’ Compensation Court for approval of treatment.
No. You have the right to refuse any invasive medical treatment (treatment that breaks the skin). Your benefits cannot be stopped for refusing this type of treatment. However, you may be found to be at maximum medical improvement if you choose not to have surgery and there is no other treatment that will improve your condition.
Yes. Injured workers frequently suffer from more than the physical aspects of an injury. It is not uncommon to suffer mental distress when struggling to adjust to disability and loss of income. Workers’ compensation covers the cost of mental health care for emotional problems that develop as a result of being injured and out of work.
Yes. The insurance company has the right to have you examined at reasonable times by a doctor of their choice. You must attend the exam – failure to attend an IME or if you obstruct an IME is grounds for the insurance company to petition the court for an order suspending your benefits. You are entitled to be reimbursed for your cost of transportation to the exam and the insurance company must send you a copy of the report prepared by the IME doctor.
Usually, the insurance company is looking for an opinion from their own doctor as to whether you’re no longer disabled and whether you need any further medical treatment. They may also want an opinion as to whether treatment recommended by your doctor is necessary. For example, they may want an IME before authorizing surgery.
A few different things can happen. If the IME report says that you’re not disabled, the insurance company may file a petition to discontinue your weekly benefits. If the report says that you’re disabled but don’t need any further medical treatment, the insurance company may file a petition for an order finding you to be at maximum medical improvement to start the process of seeking a thirty percent reduction in your weekly check. They may also use the report to deny medical treatment.
Basically, "suitable alternative employment" is a legal term used to describe a light duty job offered by an employer that you are physically capable of doing. If you accept the job, then you will receive weekly workers' compensation for part of the difference between your average weekly wage from your regular job and the weekly earnings in the "suitable alternative employment" job. If you refuse the "suitable alternative employment" job, the insurance company may file a petition against you in court. If the judge believes that you were able to do the job that was offered, he or she can issue an order allowing the insurance company to reduce your weekly benefit to what it would have been if you had accepted the job, i.e., your weekly benefit will be reduced based on the difference between what you were paid in your regular job and what you would have been paid if you accepted the "suitable alternative employment" job.
You refuse the job at your risk. An employer usually offers suitable alternative employment after having the job description reviewed by a doctor on their behalf or by your own doctor. An insurance company will probably file a petition against you in court if you refuse the job. A judge will review the job description as well as medical reports from your doctor and the insurance company’s doctor. If the judge believes that you could have done the job, then he or she may enter an order allowing the insurance company to reduce your weekly compensation payment to what it would have been if you had accepted the job, i.e., weekly compensation will be reduced based on the difference between what you were paid in you regular job and what you would have been paid if you accepted the “suitable alternative employment” job.
No. A job is considered "suitable" regardless of what it pays. If you accept a "suitable alternative employment" job, your weekly compensation benefit will be based on the difference between the average weekly wage from your regular job and your weekly earnings in the suitable alternative employment job.
If you lose the "suitable alternative employment" job for any reason other than your misconduct, then your full weekly compensation benefit will resume automatically. This is the protection offered to injured workers who return to jobs that have been identified as "suitable alternative employment". In this way, suitable alternative employment offers job security to injured workers.
If you are disabled from your regular job, you can only be penalized for not accepting a light duty job if the offer of the job is called “suitable alternative employment” in a letter to you. If a job is offered to you and it is not called “suitable alternative employment” in a letter to you, then you have the right to refuse the job without affecting your workers’ compensation benefits.
No. A return to work at light duty is not the same as a return to "suitable alternative employment". A light duty job only offers the protections of "suitable alternative employment" if it is documented in writing with the Director of the Department of Labor as a return to "suitable alternative employment". Injured workers who return to light duty without it being documented as "suitable alternative employment" run the risk that they would not be reinstated to weekly workers’ compensation benefit if they are laid off. This is particularly true for injured workers who return to light duty jobs at their regular pay.
No. Pain and suffering is not a benefit under workers’ compensation. Pain and suffering is only paid in negligence claims. Workers’ compensation is the exclusive remedy against employers for work related injuries. Therefore, you cannot sue your employer for pain and suffering for a work related injury even if your injury was caused by the negligence of your employer or a co-worker.
Yes. In addition to collecting workers’ compensation, you have the right to make a claim against anyone other than your employer whose negligence caused your injury. This is called a third party claim. For example, you may have a claim against the driver of a vehicle that caused an accident. You may have a claim against a general contractor for an injury on a construction site while you were working for a sub-contractor. Other claims are those against manufacturers for defective machinery, against premises owners for a defective condition that caused an injury and claims against maintenance companies for failing to keep an area safe and free of defects such as ice in a parking lot. These are just a few examples of the types of third-party claims that you may have.
Yes. The workers’ compensation insurance company will have a “lien”, or claim, against any money you recover from a negligent third party. A negligence case will entitle you to recover for all of your lost earnings, medical expenses and pain and suffering. Since part of your lost wages and all of your medical expenses were paid by workers’ compensation, you are required to reimburse the insurance company that paid your benefits from any money you receive in your negligence case. In this manner, you do not collect twice for the same claim and the workers’ compensation insurance company gets reimbursed by the party who was ultimately found responsible for your injury. Very often, the amount to be reimbursed is subject to negotiation.
Social Security Disability is a program that pays a monthly benefit to people who are unable to work. You must have worked long enough (typically 5 out of the last 10 years) to qualify for the program.
Social Security defines disability as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months”. This means that you must be unable to perform certain types of work because of a medical impairment that has lasted or is expected to last for one year. In determining whether you can work, Social Security also considers your age, education and work experience.
Yes. Your monthly Social Security Disability benefit may be reduced based on your receipt of workers’ compensation. However, you will continue to receive your full workers’ compensation check if you are awarded Social Security Disability.
There are many levels of appeal available to you. The first step is to file a Request for Reconsideration. If you are denied again, the next step is to file a Request for Hearing before an Administrative Law Judge. Most cases that have been denied are won at this level. If you are still denied, you have the right to appeal further to an Appeals Council and to Federal Court. An attorney can help you appeal for benefits if your application was denied.
Typically, attorneys only charge a fee if you win your case. The fee is usually 25% of past due benefits that are awarded up to a maximum fee set by the Social Security Administration.
The amount of your Social Security Disability benefit will be recalculated after you settle your workers’ compensation case. The settlement Order from the Workers’ Compensation Court can include certain specific language that will typically result in an increase in the Social Security Disability benefit if you are not already receiving your maximum benefit.
You may be eligible for benefits under an insurance policy that provides long term disability benefits. Many employers offer these policies as a benefit of employment. An attorney can help you appeal for these benefits if you are denied.
No. You cannot collect TDI and workers’ compensation at the same time.
Yes. If you have a claim pending for workers’ compensation, you can collect TDI until your claim is decided. The TDI department will pay benefits when they receive the case number of the petition for workers’ compensation benefits filed in court. If you are later awarded workers’ compensation, the insurance company will reimburse TDI from the workers’ compensation benefits that were due to you for the same period of time that TDI was paid.
You cannot collect unemployment benefits if you are receiving workers’ compensation benefits. However, you can collect unemployment benefits if your workers’ compensation benefits stop after you’ve recovered from your injury and if your former job is no longer available.
Most employers are subject to workers’ compensation laws and are required to purchase workers’ compensation insurance to cover employees for work related injuries. Benefits are paid by the employer’s insurance company. Some employers are allowed to be self-insured for workers’ compensation.
It depends. When an insurance company pays benefits, they are required to file either a Non-Prejudicial Agreement or Memorandum of Agreement with the Department of Labor (they choose which form to file) and send a copy to the injured worker. The Non-Prejudicial Agreement allows the insurance company to pay benefits without accepting liability for the injury and also allows payments to be stopped at any time during the first thirteen weeks of disability. The Memorandum of Agreement, on the other hand, signifies the insurance company’s legal acceptance of the claim and prohibits payments from being stopped without the injured worker’s written consent (on a Suspension Agreement) or court order. Injured workers who have not had their claims accepted through a Memorandum of Agreement have the right to petition the Workers’ Compensation Court for acceptance of their claims. The court order will have the same force and effect as a Memorandum of Agreement in prohibiting payments from stopping without your written consent or court order.
Workers’ compensation remains the responsibility of the insurance company regardless of whether your employer remains in business.
In general, the insurance company that paid your benefits remains responsible for your injury even if you return to work for a different employer. The insurance company remains responsible to pay for any medical care that you need for your injury and to pay disability benefits if your injury again becomes disabling, provided that you did not have a new injury with your current employer that aggravated your old injury.
Your new employer’s insurance company may become responsible for your old injury if you have another injury with your new employer that aggravates your old injury or if the nature of the work that you are doing aggravates your old injury. This is often the subject of dispute between the insurance companies for your old employer and your new employer – whether your medical condition is due to the effects of the old injury or whether it’s due to the old injury becoming aggravated by your current job or a new injury in your current job. Either way, you’re covered.
Insurance companies have the right to have an investigator perform surveillance activities on you. This may include following you, taking photographs and video, and talking to your neighbors. Insurance companies hire investigators to see if you’re doing any physical activity that might suggest that you’re not disabled or if you’re working somewhere and not reporting your wages. It’s a nuisance but perfectly legal as long as the investigator does not violate any laws such as trespassing.
Yes. You can live anywhere in the world and the insurance company will send your check to your new address. The insurance company must also continue to pay for medical treatment near your new residence.
People have different opinions on nurse case managers. Some find them helpful with coordinating medical care for complex injuries. Others find them an unnecessary interference with their patient-doctor relationship. Nurse case managers report directly to the insurance adjustor that is handling your claim. The bottom line is that it’s your decision whether to allow a nurse case manager to assist you with your medical care.
Only in very rare cases is an employer responsible for paying your health insurance. In most cases, you are required to continue to pay whatever you were paying before your injury to keep your health insurance in effect. If your health insurance is terminated, you probably have a right to continue coverage under COBRA.
If you’re out of work because of an injury, you may be eligible for up to 12 weeks of leave under the Family and Medical Leave Act (FMLA) during which time you cannot be fired. After that, or if you’re not eligible for FMLA leave, you can be terminated from your job even if you are collecting workers’ compensation. However, subject to certain limitations, Rhode Island law does provide injured workers with a right to be reinstated to their job for a period of one year following the injury. This right to reinstatement exists even if you’ve been fired.
Yes. You are entitled to be reinstated to your regular job if your employer had more than 9 employees and your job is still available. If it’s not available, you have the right to be reinstated to any other job that is vacant and suitable. There are many rules that must be followed to make a request for reinstatement. In general, reinstatement must be requested by the earlier date of one year from the date of disability, 30 days from a finding of maximum medical improvement, or 10 days from the date that you are notified in writing that your doctor released you to return to work.
Rhode Island law requires the insurance company to pay the injured worker’s attorney for successfully representing the injured worker in court. Typically, attorneys don’t charge injured workers for any work at all except in cases of settlement. If a case settles, the attorney’s fee is limited to 20% of the settlement.
It’s never too soon to speak with an attorney after you’ve been injured to make sure that your rights are protected. Workers’ compensation cases can become difficult for injured workers, especially as claims get older and the interests of the injured worker and the insurance company begin to diverge. All sorts of problems may arise between you and the insurance company ranging from denials of medical treatment to attempts by the insurance company to reduce or discontinue your benefits. The typical injured worker does not know the law whereas insurance companies know the workers’ compensation system very well. An attorney will educate you about your rights and obligations under the law, as well as those of the insurance company, so you can make good decisions about your case. Your attorney will support you in enforcing your rights, explaining your obligations, and protecting your from any trouble that may come from the insurance company. Most attorneys don’t charge any fee unless you settle so it is usually good sense to have an attorney on your side to protect your rights.
Yes. You can always switch to a new attorney without it costing you any money. Your new attorney will share any fee he or she receives with your former attorney as payment for services rendered.