We have included useful videos, information, and guides on our website to help you understand how workers' compensation works in Georgia.
Workers' compensation is a type of insurance that is meant to cover people who get injured at work. This insurance is mandatory for most employers. This system covers over a quarter of a million employers in Georgia and over 3.8 million workers.
There are very specific rules about who is entitled to draw these insurance benefits. The rules are listed in Georgia Code Title 34, Chapter 9 and the rules and regulations published by the State Board of workers compensation. You can click here to see a copy of the rules published by the State Board of Workers Compensation (Warning: these are long, boring administrative rules and many lawyers don't even undertand what they mean).
The rules that apply to workers compensation can be confusing, arbitrary and harsh. A small mistake can end up costing you thousands of dollars in lost benefits. There are rules about notifying your employer when you get injured, who is in charge of selecting the treating doctor, when and how you're able to change doctors, how long you can draw a weekly check, when you can get a hearing in front of a worker's compensation judge, etc. There is a big difference between being entitled to workers' compensation benefits and actually receiving them
When you have a workplace injury, none of your workers compensation benefits are guaranteed. The burden is on you to prove you are entitled to benefits. The insurance company is actually considered to be your "adversary" in this process. They have no duty to treat you fairly. The workers compensation insurance company is going to try to mess up your case and pay you as little as possible. The system is not designed to be fair. But, the insurance adjuster is an expert at using the rules to cut off your benefits as soon as possible.
Georgia's workers compensation system was develeoped in the early twentieth century, when industrial accidents and factory accidents were very common. Working people were getting disabled and hurt at alarming rates. After an injury, working people were often left penniless and completely unable to support their families. Sometimes, an injured worker could prove that his injury was because of their employers negligence. In those realtively uncommon cases, the employee could sue their employers for negligence and recover damages. Sometime a large lawsuit could put an employer out of business.
In 1920, Georgia adopted the workers compensation Act to solve those problems. The first purpose of Georgia's Workers' Compensation Act is to ensure employees can secure benefits after workplace injuries. The second purpose is to prevent lawsuits against employers when a worker is injured.
Workers' Comp is a "no fault" system. You are entitled to benefits regardless of who might be at fault for the accident. You can recover workers comp benefits even if the accident was the result of your own careless mistake.
There are four primary types of benefits injured workers' are entitled to receive.
There are very specific laws and rules about what qualifies as a "work accident". Often times, cases will be denied when the insurance company argues that your injury did not meet the "statutory definition" of a work accident.
Proving that you had a work accident is often more difficult than you might think.
It is your burden to prove that your accident happened during your employment and that your accident was caused by employment. In the law, having a "burden" means that you are not entitled to anything until you prove your case. For example, The insurance company can claim that all of your problems are pre-existing and were not caused by the accident at work. Another common tactic is that the insurance company will say you lied about the accident happening at work because there were no witnesses. If your claim is denied, the burden is on you to request a hearing and submit evidence to prove that your injury was a work-related-accident.
First, for an injury to be considered valid under workers compensation, the injury must occur on the job. This is called an injury "in the course of employment". This simply means that you were injured during the time you were actually on the clock for your employer, or while you were doing something incidental to your employment (such as entering or leaving the work premises). Another example would be driving to the Bank to drop off a check for your employer. This would be in the course of your employment even if it was outside of your work hours.
Second, your injury must be caused by something related to your employment. For example, if you slip on a wet floor at work, the injury was clearly related to your employment. If both of the conditions above are met, then you would have a worker’s comp injury.
Workers' compensation is a lot like a game of chess. When you make a workers' compensation claim, you are making a claim for insurance benefits that could potentially cost the insurance company hundreds of thousands of dollars or more. The stakes are high. You are potentially entitled to receive lost wage benefits, medical benefits, and money for permanent impairment. I have personally seen thousands of cases that have gone off-track because the injured worker did not have a lawyer. You are taking a risk trying to navigate this system on your own.
But even a denied case can be very valuable. According to one study about workers' comp, 67 percent of denied claims are converted to paid claims within a year. Think about that for a minute: on average, more than two out of three denied claims will pay out! In an ideal world, employers would never deny a valid claim. Why do the insurance companies deny so many valid workers' comp claims?
A significant amount of injured workers will never file a claim or hire a lawyer. Some people may think it is not worth the trouble to fight the denial, and end up billing their health insurance or medicare. Because of this, our workers' comp system incentivizes employers and insurance companies to deny cases. A back injury with a herniated disc can easily cost over $100,000 in medical bills alone. If an injured worker never files a claim after the intial denial, all of that money becomes profits for the insurance company's shareholders. The insurance company really hopes that you just give up on your workers compensation claim, because they know many people do give up after the first denial.
After you notify your employer of the accident, they are required to report the injury to their insurance company. The insurance company will investigate the claim. The insurance company can either accept your claim, accept your claim as "medical only", or deny your claim entirely.
In an accepeted case, the insurance company will start paying your benefits voluntarily without the need for a hearing. Workers' compensation often works very well for people who have short term injuries requiring only a few doctor visits. For example, if you need stitches and do not miss any time from work, then you likely won’t have many problems with workers compensation. But if you have a medical problem that will last months or years, you have just entered a fierce competition with the insurance company.
Workers comp can still deny your benefits even when they accept that you had an on-the-job injury. For example, they will often claim your medical treatment is "not necessary", therefore they don't have to pay you. There are also numerous reasons they try to avoid paying your income benefits.
If the insurance company accepted your injury, but is denying some or all of your benefits, you should get a free consultation with a Georgia Workers' Comp attorney.
In a "medical only" case, the insurance company has accepted that you suffered a workplace injury, but is not paying you for any lost time from work. They are only paying medical benefits.
In a denied or "controverted" case, the employer is denying that you had a compensable workplace injury. Workers' compensation law is complicated and the reasons an insurance company can deny a claim are numerous. Technically, the insurance company has up to 81 days to deny your entire case. They can still deny your case after 81 days if they never paid you a weekly check or based on on "newly discovered evidence." Some common reasons are: they say you are lying about the accident, that you failed to disclose a pre-existing condition, or that your accident was the result of intoxication.
Even a denied case can be very valuable. Even very good cases are denied all the time. You just need to hire a lawyer to request a hearing to have your benefits started. But don't wait. There are many deadlines in workers compensation law.
The system is not designed to work well for someone with a serious, long-term injury who is unrepresented. Delay of treatment is common. I can help get your medical treatment approved faster, and prevent your benefits from being terminated without legal cause.
When the insurance company tries to delay my clients treatment, I file a petition for medical treatment (WC-PTM) with the state Board of workers compensation. This form gives the insurance company only a few days to respond.
I have even seen insurance adjusters tell my clients that their case was "closed", only to find out that my client was legally entitled to lifetime medical benefits.
You should do your research and carefully consider the benefits of hiring a workers comp attorney to help you navigate the system.
There is never an up front cost to hire me, and I will help keep your case on track. I prefer to get involved early on in your case, before the insurance company is able to mess up your case. It is a lot like getting a car stuck in a ditch. We can tow you out, but it is better not to drive into the ditch in the first place.
Here some common reasons it may be a good idea to consult an attorney in your workers' compensation case.
Delay of benefits is a huge deal in workers compensation. Most doctors will not treat you unless they get "authorization" from the insurance company. Pre-authorization is not actually required by law, but the doctors want to make sure they will get paid before providing treatment. Denial of medical treatment is very common. We help our clients get their treatment approved every single day.
If your doctor sends you back to work without restrictions you will generally not be entitled to workers' comp income benefits for missed time. This will be a problem if you still have physical issues related to your accident. If this happens, we can help you to switch doctors or get a second opinion.
Denials for pre-existing conditions are very common. This might be one of the most common reasons medical treatment gets unfairly denied. The insurance company and their lawyers will often contact your treating doctor and try to get them to say that your problems are not the result of the work accident, but rather a pre-existing condition.
But, pre-existing conditions are actually covered by workers' compensation. It is your burden to show that they accident at work aggravated your pre-existing condition (i.e. made it worse). Meeting this burden often means getting a written opinion from your treating doctor. An attorney will help you to do this.
Workers' compensation has a complicated system for picking doctors. You should never let the insurance company pick the doctor. You actually have a right to choose a doctor from a list (or choose any doctor you want if there is no list).
The doctor you select is probably the single most important decision in your case. This doctor will affect your rights to lost income benefits, future treatment, money for permanent impairment, etc. You should get a free consultation with an attorney before you select the doctor.
If this happens don't panic. Even a "denied" can be very valuable. Unfortunately, the laws about who is covered can be insanely complicated. An experienced workers comp lawyer will help determine if you have a valid claim.
In our experience, the insurance company will frequently deny a claim even if they think there is only a 10 percent chance they can win. Why would the insurance company do this? It is really just about money. Many people give up on a good claim and never hire a lawyer.
Remember that the insurance company is your adversary and they do not have to treat you fairly. You have a right to request a hearing in front of a workers' compensation judge who will decide if you are covered by workers compensation insurance.
Even if your claim was initially accepted, the insurance company might try to have you re-evaluated by a "company" doctor. Often, the independent medical examination (called an IME) is a precursor to terminating, reducing or eliminating your benefits.
An IME is not actually "independent". This doctor is chosen by the insurance company. This doctor is paid up to $1200 to create a report about your accident. The IME doctor might only meet with you for 10 minutes. You are not considered a "patient" of this doctor, therefore the rules of medical ethics do not apply to this doctor's report. He also knows that he will likely never see you again after the first visit (but will continue to get business from the insurance company). He is basically an expert witness for the insurance company. The report might say that the treatment recommended by your doctor is not necessary, that you are exaggerating symptoms, that your injury is not work related, etc.
Usually you will be sent to an IME when the insurance company is looking for a reason to deny your benefits. If you get a notice for an IME, contact a workers' comp attorney.
Getting the maximum amount for your workers compensation case can be tough. Click here to learn how an attorney can help maximise your recovery
If the case settles , the attorney cannot charge more than 25% of the settlement. Costs are additional. You do not owe the attorney fees or costs if they do not make a recovery for you.
But be careful!
Costs are one area where an attorney can pull a fast one on you.
Before hiring a workers' comp attorney, ask if they will itemize will give you an itemized list of the costs when your case closes. I do. When you settle, you don’t want to see that costs are $5000, but with no actual breakdown.
In addition, ask the attorney if he or she will get your consent before incurring a cost over a certain amount. I am happy to do so.
I do everything I can to keep the costs in your case reasonable. This often means fighting with medical records providors or court reporting companies that try to sneak in exorbitant fees. Many attorneys don't bother to do this because they don't care about the costs. High costs can eat away at your portion of the settlement
Here is an example of a workers' compensation case I settled.
There are also certain situations where I will never charge you a dime. Sometimes a person hires me to get advice and help immediately after an injury, but the insurance company never denies any benefits. If I don't get benefits started for you or negotiate a settlement, I never charge a fee in your case. This is one of the huge benefits of hiring a lawyer on a contingency. There are no cons to getting a lawyer involved early in the case to help guide you through the process.
Workers' compensation is not a perfect system. It is overly complicated and the benefits can be confusing. Read our guides to find out what benefits you may be entitled.
In a major victory for injured workers, injuries during scheduled lunch breaks are now covered by workers compensation.
Ask the right questions before you hire an attorney for your workers comp case.