Eligibility Requirements for Workers’ Compensation Benefits

Workers’ Compensation benefits are designed to protect both employees and employers against the losses resulting from a work-related injury, illness, or fatality. Despite this, insurers reject more than 25% of Workers’ Comp claims in the U.S. in the first round. The main reason is that some covered employees are ineligible for benefits because they do not meet the set requirements.

With that in mind, here are some eligibility requirements for Workers’ Compensation benefits to remember.

  1. You Must Be an Employee
    As mentioned above, Worker’s Compensation insurance caters to employees who suffer work-related injuries. It is worth noting that to be eligible for Worker’s Compensation benefits, one must be an employee as per your employer’s classification. Therefore, independent contractors and those working in the gig economy are not eligible for these benefits.
  2. Employers Must Have Workers’ Compensation Insurance Coverage
    While most states across the U.S. require employers to carry Workers’ Compensation coverage, Workers’ Comp laws generally vary across state lines. Employers must have a valid Workers’ Compensation insurance policy for employees to qualify for Worker’s Compensation benefits, and policies must be up-to-date in terms of payment of premiums.
  3. The Injury Must Be Work-related
    More than 12,000 American workers suffer work-related injuries every day, and to qualify for Workers’ Compensation benefits, the injury or illness must be directly related to one’s work. For instance, you won’t qualify for Workers’ Comp benefits if you get involved in a road accident while using a company vehicle when running personal errands. This is because the insurance provider will define the injury as work-unrelated, even though you were using a company vehicle.
  4. The Injury Must Be Reported Within the Allowed Time Frame
    The Workers’ Comp claim process starts with the injured worker reporting the injury to the employer. Once reported, the employer will be responsible for informing the insurance company about the injury and filing a Workers’ Compensation insurance claim. All this must happen within a specific time frame, which varies by state. For instance, in Massachusetts, the employer has seven working days to report the injury. After that, they must file a Workers’ Comp claim within four years. If the employee or the employer miss the deadlines for reporting and filing a claim, the employee will lose their eligibility for Workers’ Compensation benefits.
  5. The Insurer Must Approve the Claim
    It is one thing to file a Workers’ Compensation claim and another to have it approved. Before the insurance provider approves a Workers’ Compensation claim, they conduct a thorough investigation concerning the work-related injury. This process helps to gauge the genuine cases amid rampant insurance fraud. If the employer finds evidence suggesting foul play regarding an employee’s Workers’ Comp claim, the employee will likely lose their eligibility for Workers’ Compensation benefits.

How to Find the Right Workers’ Compensation Plan for Your Employees

These are the basic eligibility requirements for receiving Workers’ Compensation benefits. For information about tailored Workers’ Compensation insurance solutions, contact our experts at PMC Insurance Group today at [email protected]

By PMC Insurance Group

Since 1996, PMC Insurance Group has worked to help independent agents grow their client base by offering workers' compensation solutions for a wide array of businesses. As one of the most distinguished workers' compensation wholesalers in the country, we have the tools and resources to help you create coverage programs for small businesses and large accounts.