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Workers Compensation: What Is Actually Covered?

Workers Compensation: What Is Actually Covered?

Having been a Charleston Workers’ Compensation attorney since I graduated law school in 1997 I’ve spent many hours, months and years digging down into the complexity’s of the South Carolina Workers’ Compensation system. But on the most basic level, what my clients want to understand most when they first come into my office to seek guidance and legal advice, is “what does Workers’ Compensation cover in South Carolina?” As with almost any legal question, there is both a short simple answer and a more in depth complex answer that more explains what an injured worker could expect the South Carolina Workers’ Compensation Act to cover for them after they’ve been seriously injured on the job.

First, it’s important to note that the South Carolina Workers’ Compensation laws were written in 1935 in an attempt to provide medical treatment and compensation to injured workers in South Carolina. The Act requires the injured worker to bring his or her claim in front of the South Carolina Workers’ Compensation Commission (hyperlink to South Carolina Workers’ Compensation website here). In your typical case, the first thing that Workers’ Compensation would cover would be 100% of your medical care and treatment. So for example let’s say that you were lifting a box and felt a pop in your back and then reported the accident to your employer, the first thing of course that you’d want to get is an evaluation by a qualified doctor to determine the extent of your injuries caused by your accident. So the Workers’ Compensation Act requires your employer to send you to a doctor of their choosing to evaluate you and come up with a medical care treatment and plan, if any. This of course is where a lot of friction between your employer and/or the insurance carrier can begin in that many times they want to send you to the “company doctor” and not send you to the type of qualified specialist that would be best to address your medical injury and your medical needs.

Once you see the appropriate specialist (for example if you injured your back at work you would want to see either a qualified orthopedic specialist or a qualified neurosurgeon), then the next step is you would be entitled to all proper testing to make a proper diagnosis of your injury from you work accident. Many times this is simple as an examination review by the doctor but in other instances can be an x-ray all the way up to an MRI, a CT scan, or some type of CT Arthrogram just to name a few. This type of testing can help lead to a proper diagnosis which in turn can lead to a proper treatment plan to help you get back to 100% or as close to it as you possibly can after your work accident.

Unfortunately, in South Carolina, the employer and their Workers’ Compensation insurance carrier are aloud to choose the doctor that will treat you in your case. So while it may be that the Workers’ Compensation Act does cover your medical care and treatment, many times it is in your best interest to go and seek an Independent Medical Exam to get an independent look from a doctor of your choice to determine the extent of your injuries and what the proper treatment plan should be. So the underlying theme of your case and of this article is that you’re not only wanting to know what the Workers’ Compensation Act covers in South Carolina you also want to know what are the reasonable strategies to prepare your case.

The next thing after you get your medical treatment is naturally wanting to know what type of money benefits you would be entitled to in the event that you are not able to return to work in the short term or the long term after your work accident. So, what does the Workers’ Compensation Act cover in this area in South Carolina? Well the answer is that you may be entitled to what is known as Temporary Total Disability benefits or Temporary Partial Disability benefits. To determine which of these benefits you may be entitled to, the first analysis is to determine what your work status is following your work accident. So for example if the doctor sends you back to what is known as “full duty employment” then naturally you would return to your job that you’re working at the time of the accident and continue to work in that capacity earning the same wages as you did prior to the work accident. In that case there would be no short term money benefits available to you in your case. However, importantly, in the event that the doctor wrote you totally out of work and said that you are unable to return to your prior work or any other type of work as a result of your injuries, then you would be entitled to Temporary Total Disability benefits under South Carolina law.

In the event that you are entitled to these weekly benefits, it is important to note that they are supposed to be paid one time per week and on a “regular basis”. Furthermore you are supposed to receive 2/3 of your Average Weekly Wage which is known as your Compensation Rate. Importantly this money is supposed to be tax free so while you will only be getting 2/3 of what you are earning on the job as a weekly benefit through the Act. Also importantly, the money you receive should not be taxable and therefore in theory you should be earning approximately what you were earning at the time of the accident through these benefits.

In the event that you are able to return to work but not able to earn the same type of wages that you were earning before the accident, either because you’re working fewer hours or because you’re working a different job at a lower rate or a combination of these two, then you would likely be entitled to Temporary Partial Disability benefits. In this case you would take your pre accident Weekly Wages and then you would subtract out your post accident Weekly Wages. This would leave a number that would show the amount of money you are losing per week. Under the Act you would then be entitled to 2/3 of the difference between your pre injury weekly earning capacity and your post injury weekly earning capacity. So for example if you were earning $600 per week prior to the work accident, and now can only earn $300 per week, then your loss per week would be $300. Under South Carolina law you would be entitled to 2/3 of the money’s loss. That means in this example you would be entitled to 200 additional dollars per week. So between the $300 you are still able to earn after the accident plus the $200 in Temporary Partial Wage Loss that you’re receiving from the Workers’ Compensation Act you would be bringing home a total of $500 per week. Again this $100 loss that you’re receiving per week is a disadvantage however because the money you’re receiving under the Act are not taxable theoretically this should put you in a similar position to that in which you were when you were earning wages before the accident and were having your taxes taken out of your paycheck.

So now having established that Workers’ Compensation will cover your medical treatment and also will cover paying you for being totally out of work on a temporary basis or partially out of work or earning less wages on a temporary basis, we now turn to what does Workers’ Compensation cover beyond medical and weekly compensation? Workers’ Compensation will also cover any mileage that you have incurred in going to and from your medical appointments. The insurance carrier is suppose to pay you the amount per mile that state employees receive for reimbursement for mileage use operating in their official capacity. This amount of money is published from time to time on several government agency websites and is information that is fairly easy to ascertain. (Hyperlink to state agency). So while this may not be a tremendous benefit in that the amount of miles that will accumulate over your case probably will not reach into the thousands of dollars for example, it is still money that does not have to come out of your pocket as an expense to you when you’re traveling back and forth from your authorized medical appointments in your case. Also in many cases you can have the Workers’ Compensation insurance carrier reimbursement for some “out of pocket” expensive that you incur in the early stages of your claim sometimes before the insurance company was involved in authorized medical care and treatment. Some examples of this would be when your employer sends you to your family physician or to the company doctor but on that particular day of the first visit you do a “self pay” rate or file it on your private health insurance. Why you should never file Workers’ Compensation medical treatment on your private health insurance, from time to time this has been known to happen and when it does the Workers’ Comp. insurance company should of course reimburse your private health insurance for whatever they paid for that visit or visits to the doctor but also importantly, should reimburse you for any deductibles or co pays or other out of pocket expenses that you incur as a result of the medical treatment visit.

Another thing that Workers’ Compensation will cover in many cases are the other types of medical equipment and devises that are prescribed by your authorized treating doctor for your home to help assist you with your “daily living activities”. So for example your doctor may recommend that railings be put in your shower or around your toilet area to assist you getting up and in and out of these various locations in your home. Furthermore you may also find that the Workers’ Compensation insurance carrier is responsible to pay for things that will help you in terms of modifications to your vehicle to drive it including maybe even making adjustments to a van or car to make it wheelchair accessible for example or to make the car operable in the event that you are unable to operate the car without some type of hand control devise as a result of and after your work accident injuries. In extreme examples many times Workers’ Compensation insurance carrier will be responsible for paying for home health care in the event that the injured workers’ injuries are truly catastrophic and require that there be some type of home attendant care to assist them with their daily needs.

Having now established what you could expect from a Workers’ Compensation case from a medical standpoint from a weekly compensation standpoint and from the catch all category of all other types of medical assistive devices home improvements and so forth, we next turn to what does Workers’ Compensation cover in terms of your permanent disability, if any, in your case? The answer to this of course revolves around whether or not you are able to return to your prior job or career and/or whether or not you have Permanent Total Wage Loss or Permanent Partial Wage Loss as a result of your work related injuries. In the event that you’re able to return to your prior job earning the same or better money as you did prior to your work injury, then workers’ compensation will typically provide you for what is known as “general disability” or “permanent partial disability” herein after “PPD”. In this event your doctor will have likely given you some type of impairment rating to your injured body part. You would then lets say for example you injured your back and you doctor gave you a 15% impairment to your back as a result of your work accident and injuries. You would then move to the disability statute and get some percentage of weeks for your disability to the back and large part based upon the permanent impairment rating given to you by your authorized treating doctor in your case. In the event that you’re not able to return to work and you suffer Total and Permanent Wage Loss, then you could move to have payments made to you, sometimes in a lump sum payment, for Permanent and Total Wage Loss in your case. Typically a Total and Permanent Wage Loss case is capped at 500 weeks of benefits and also is adjusted to what’s known as the “commuted value” of the benefits that will be payed to you. The South Carolina Workers’ Compensation Commission publishes the commuted value tables (hyperlink to commuted value tables on commission website) to inform the injured worker their attorney the insurance company whoever may be looking at the issue as to what the commuted value is of the injured workers’ disability benefits. In the event that you are able to return to work just not able earning the same amount of money as you did before the accident or working fewer hours then you did before the accident or some combination of the two then you would be able to move for Permanent Partial Wage Loss and seek payment of 2/3 of the difference between your pre accident earnings and your post accident earnings. However the pay out for your Permanent Partial Wage Loss would be capped at 340 weeks per South Carolina law.

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