Workers' Compensation Claims Flashcards

The 'exclusive remedy' doctrine in workers' compensation means that:

Answer: Workers' compensation is generally the sole remedy an employee has against the employer for work-related injuries

In exchange for no-fault coverage, workers typically give up the right to sue their employer in tort, making workers' compensation their exclusive remedy.

An injured worker who willfully and intentionally injures himself to collect workers' compensation benefits would most likely have the claim:

Answer: Denied due to intentional self-infliction

Intentional self-inflicted injuries are a standard exclusion under workers' compensation statutes and the claim would be denied.

Under most state laws, which party selects the initial treating physician in a workers' compensation claim — the employer/insurer or the employee?

Answer: It varies by state statute

Physician selection rules differ significantly by state — some grant employer control, others give the employee free choice, and many allow a mix.

Death benefits in workers' compensation are typically paid to:

Answer: Surviving dependents such as spouse and minor children

Workers' compensation death benefits are payable to statutory dependents — usually the surviving spouse and dependent children — not the estate.

A second-injury fund (also called a subsequent injury fund) is designed to:

Answer: Encourage employers to hire workers with pre-existing disabilities by limiting their liability for combined impairment

Second-injury funds absorb the portion of disability attributable to the pre-existing condition, reducing employer liability and promoting hiring of disabled workers.

A workers' compensation claim adjuster's primary ethical obligation when handling a disputed claim is to:

Answer: Conduct a fair, impartial investigation and make a good-faith coverage decision

Good-faith claims handling requires an impartial investigation and a timely, honest coverage decision based on the facts and applicable law.

In most states, what is the standard method for calculating a workers' compensation claimant's Average Weekly Wage (AWW)?

Answer: Total wages earned in a look-back period (commonly 52 weeks) divided by the number of weeks worked

AWW is typically calculated by dividing the claimant's total gross earnings over a statutory look-back period by the number of weeks actually worked.