The benefit structure defines what injured workers are entitled to receive when they sustain an injury "arising out of and in the course of" their employment. There are four basic types of workers' compensation benefits available, depending on the nature and severity of the worker's injury: (1) medical care, (2) temporary disability benefits, (3) permanent disability benefits and (4) death benefits.
Injured workers are entitled to receive all medical care reasonably required to cure or relieve the effects of the injury, with no deductible or co-payments by the injured worker. Generally, the employer controls the medical treatment after the injury is reported. However, if the employee has notified the employer prior to the injury that he or she has a "personal physician" -- a physician or surgeon who has previously treated the employee -- the employee may be treated by that physician from the date of injury. Choice of treating physician differs, however, if the employer and employee have opted for a managed care program. An insurer or employer may establish a medical provider network (MPN) for the provision of medical treatment to injured employees. If an employer or its insurance carrier is part of MPN, the employee has the right to designate any doctor within the MPN as his or her primary treating physician. Medical treatment for injuries shall be readily available at reasonable times to all employees.
Temporary Disability Benefits
Those workers unable to return to work within three days are entitled to temporary disability benefits to partially replace wages lost as a result of the injury. The benefits are generally designed to replace two-thirds of the lost wages, up to a statutory maximum depending on the date of injury. For injuries after 1/1/11 there is a maximum of $986.69 per week.
Temporary disability benefits are payable every two weeks, on a day designated with the first payment, until the employee is able to return to work or until the employee's condition becomes permanent and stationary. There are statutory limits as to how long these benefits will last if the employee does not return to work. For example, for all injuries after 1/1/08, the maximum period to receive temporary disability benefits is 104 compensable weeks within a five year period from the date of injury. For certain specified injuries, the maximum is 240 compensable weeks within a five year period.
Permanent Disability Benefits
Injured workers who are permanently disabled -- those who have a permanent labor market handicap -- are entitled to receive permanent disability benefits. A worker who is determined to have a permanent total disability receives the temporary disability benefit -- up to a statutory max per week depending on the date of injury -- for life. For example, an injury after 1/1/11, a worker will receive $986.69 for life. A worker determined to have a permanent partial disability receives weekly benefits for a period which increases with the percentage of disability, from 4 weeks for a 1% permanent disability up to 694.25 weeks for a 99.75% disability. Permanent partial disability benefits are also payable at two-thirds of the injured worker's average weekly wages, but are subject to a much lower maximum. As of January 1, 2006, the rates are $230 per week for disabilities up to 69.75% and $270 for disabilities rated at 70% to 99.75%. Those with a permanent partial disability of 70% to 99.75% also receive a small life pension -- as of 1/1/06 the maximum rate is $301.50 per week depending on the percent of disability -- following the final payment of permanent partial disability benefits. The percentage of permanent disability is determined by using the Permanent Disability Rating Schedule and an assessment of the injured worker's permanent impairment and limitations.
The Permanent Disability Rating Schedule specifies standard percentage ratings for permanent impairments and limitations, and provides for the modification of these standard ratings based on the injured worker's age and occupation. The standard rating is adjusted for age by lowering the rating for younger workers and increasing it for older workers on the theory that it is easier for younger people to adjust to a permanent handicap. The standard rating is adjusted for occupation by increasing the rating if the permanent impairment or limitation will be more of an impediment in performing the worker's occupation, and lowering the rating if it will have a lesser impact.
The assessment of the injured worker's permanent impairment and limitations is made by either the treating physician or a "Panel Qualified Medical Evaluator" (PQME). The Industrial Medical Council appoints and regulates QME's. If there is disagreement with the treating physician's opinion and the worker is not represented by an attorney, he or she chooses a physician from a three member panel obtained from the Industrial Medical Council. If the worker is represented by an attorney, the parties must attempt to agree on a physician to perform the evaluation. If they are unable to agree, either party can request a PQME from the Industrial Medical Council. A choice of three physicians is sent to the parties. Both parties have an opportunity to object to one name on the list. The last physician left on the list then becomes the PQME. The medical determinations made by the PQME are the final determinations that all parties must rely upon. If the parties are still in disagreement, it may be resolved by negotiations, or if necessary, litigation.
Death Benefits In the event a worker is fatally injured, reasonable burial expenses, up to $5,000, are paid. In addition, the worker's dependents may receive support payments for a period of time. These payments are generally payable in the same manner and amount as temporary disability benefits, but the minimum rate of payment is $224 per week. The total aggregate amount of support payments depends on the number of dependents and the extent of their dependency. Generally, the maximum (where three or more total dependents are eligible) is $320,000, though additional benefits are payable if there continues to be any dependent children after the basic death benefit has been paid.