How do I file a workers' compensation claim?
- Your employer files a claim with their workers' compensation insurance carrier. You must report your injury or illness to your employer to start the process.
What is Workers' Compensation?
- The Rhode Island workers' compensation system is a form of no fault insurance designed to provide assistance to injured employees for lost wages and medical expenses. It applies to businesses with one or more employees, unless otherwise exempt by law. Employers with one or more employees are required to carry workers' compensation insurance unless otherwise exempt by law. In case of an accident, the employer's insurance company handles the claim.
What are the injured workers responsibilities?
- Seek immediate medical attention, and report the injury or illness to your employer immediately or when you realize it is work related. If the injury incapacitates you from earning full wages for at least three (3) consecutive days or requires medical treatment, your employer is required by law to file a First Report of Injury form with the Division of Workers' Compensation within ten (10) days of the actual injury or knowledge of it. The employer must file within 48 hours if the injury is fatal.
4. Who chooses my medical care provider?
- You may choose your first medical care provider. Treatment at an emergency room after the accident or by a company physician does not count as the first medical care provider. Your first provider may refer you to a specialist without prior approval from the insurer. No matter who your treating physician is, you are entitled to receive a report from him or her within ten (10) days of each visit.
May I change doctors?
- If you decide to change doctors, you must first find out if your insurer or self-insured
employer has an approved list of physicians, otherwise
known as a "preferred provider network". If so, you must either select a physician from that list or get the approval
of your insurer or self-insured employer before you see another
doctor. If your employer or insurer does not have an approved
physicians, these restrictions do not apply.
Who pays the medical bills?
- Medical bills related to the injury should be paid in full by the employer's insurance company. There are no co-payments or deductibles.
- 7. How do I find out if there is an approved list of physicians for my employer or insurer?
- To find out if a list of physicians exists, contact your employer/insurer.
- 8. How do I find my employer's insurer?
- If you need help in determining the name of your employer's insurer, contact the Fraud and Compliance Unit at (401) 462-8100 option 4 or email WCFraud@dlt.ri.gov. Click here to find coverage.
Are there limits on medical care?
- Palliative Care limits: After maximum medical improvement has been reached, treatment to alleviate the effects of the injury is limited to twelve (12) visits or care rendered within 60 days, whichever comes first. Any additional palliative care must receive prior approval from the insurer.
What is the Medical Review: Impartial Medical Exam?
- If you receive weekly incapacity benefits for 26 weeks, the Administrator of the Medical Advisory Board will schedule an examination for you by an impartial medical examiner or a comprehensive independent health care review team. The results of the exam will be provided to you within 14 days. Failure to appear for this exam may be reason for suspension and termination of benefits. Repeat examinations will be scheduled every 13 weeks while your are receiving weekly benefits.
What is the Anniversary Review?
- The Workers' Compensation Court schedules an anniversary review once a year for all employees who continue to receive ongoing weekly benefits.
What are your benefits?
- If you are incapacitated for at least three (3) consecutive days from earning full wages and incapable of gainful employment at comparable wages, compensation benefits may begin on the fourth day from the date of injury. You may also be entitled to medical treatment, benefits for disfigurement or loss of use, or participation in a rehabilitation. Dependents of employees who suffer a work-related fatality may also receive benefits.
How are your benefits determined?
- There are several types of weekly benefits paid under workers' compensation.
Total disability benefits apply if the employee is physically unable to earn any wages in any employment. The weekly compensation rate for total incapacity is equal to 75% of your spendable base wage. Supplemental earnings and bonuses are considered in determining your benefit rate.
Partial disability benefits apply if the employee's ability to earn full wages is affected but the employee is not totally disabled. When the employee reaches maximum medical improvement, the Workers' Compensation Court may reduce the employee's compensation rate.
Dependency allowance benefits are $15.00 per dependent per week for total disability, and $40 per dependent per week for fatality benefits. There is no dependency allowance for partial disability.
- 14. What rehabilitation benefits are provided?
- You are entitled to any necessary rehabilitation services to help you regain the ability to return to work. The Dr. John E. Donley Rehabilitation Center provides services for people injured at work. Their services include physical, vocational, and psychological rehabilitation. If you have questions about rehabilitation, call the Donley Center at (401) 243-1200.
- 15. Will I receive written notice from the insurance company?
- The insurance company may offer you a Memorandum of Agreement, or MOA. The MOA means the insurance company accepts liability for your injury and should start sending you weekly benefits payments within 14 days. The insurer should send you a copy of the MOA by certified mail, return receipt requested.
As an alternative, the insurance company may offer you a Non-Prejudicial Agreement. This agreement allows the insurer to begin paying you weekly benefit payments without accepting liability for the injury for up to 13 weeks. The insurer can stop benefits at any time. Within 10 days of when benefits stop, the insurer must send you a notice called a Termination of Benefits. If you receive weekly payments for more than 13 weeks, the insurer should issue a Memorandum of Agreement. If the insurer stops payments or you return to work before 13 weeks has passed, you have two years from the date of injury to file a petition with the Workers' Compensation Court to determine if the insurer is liable for the injury.
What if I don't receive a notice from the insurance company?
- If you have not received any notice from the insurer within 21 days from the date you notified the employer of the injury, you may file a petition for weekly benefits at the Workers' Compensation Court. The insurer is not obligated to file anything or to do anything to let the employee know if the claim is contested.
What is a Suspension Agreement?
- If the insurer made payments to you under a Memorandum of Agreement, you may be asked to sign a Suspension Agreement. Signing a Suspension Agreement means that you agree to end weekly benefits payments. The insurer continues to be responsible for all reasonable medical expenses relating to your injury. The law allows you up to ten (10) years to reopen your claim.
Can I return to my job?
- In most cases, you have the right to return to your former job if you can perform your job duties with reasonable accommodation by your employer. This is known as your right to reinstatement. You must claim your right to reinstatement within ten days from the date you are notified by mail that the treating physician has released you for work. Your are entitled to reinstatement even if the job has been filled by a replacement. If that position is unavailable, you are entitled to reinstatement to any other vacant and suitable position.
If you have been denied this right, or if you would like additional information, contact the Education Unit at (401) 462-8100 option 1, or WCEdcUnit@dlt.ri.gov to get forms or to file a complaint. These requirements are subject to union contract and to the Americans with Disabilities Act.
What is Coordination of Benefits?
- There may be an offset (a reduction) of weekly compensation benefits for people who are entitled to retirement benefits. This offset will not include any benefits derived exclusively from the employee's contribution. There will be no offset for those collecting retirement who are injured before age 55 and are injured more than five years before their retirement date. No workers' compensation benefits can be collected after retirement for persons who are injured less than two years before retirement.
What is the Fraud and Abuse provision?
- Fraud and abuse provisions include penalties of up to $50,000 or double the amount of the fraud, imprisonment of up to five years or both:
-- imposed on attorneys and clients for willful abuse of court proceedings
-- for obtaining benefits through fraud or misrepresentation
-- for obtaining workers' compensation insurance through fraud or misrepresentation
-- for making false statements to discourage a lawful compensation claim
False statements include:
-- endorsement of a benefit check if benefits were obtained through fraud or misrepresentation
-- false bills
-- misrepresentation on application for insurance
Employees entitled to weekly compensation benefits must report any earnings so that the amount of benefit can be calculated properly.