How The Workers Comp Claims Process Work for Employees

In theory, the workers’ comp claims process is rather straightforward. When you get injured on the job, you file a workers’ comp claim. Then your employer and the insurance company will evaluate your claim. Based on the evidence they have, they can either approve or deny it. In the case of the latter, you can file an appeal and let the court decide on your case.

Sounds simple right? Unfortunately, filing a workers comp claim is a lot more complicated in reality.

For one, insurance companies aren’t exactly known for their generosity. So expect that they’ll come up with whatever reason to legally reduce your workers’ compensation or deny it outright.

Another factor that complicates the workers’ comp claims process is the burden of proof on your part. Workers comp laws specify that only job-related injuries are eligible for workers comp. Claiming that you got your injury while at work is one thing, proving it is another. In some states, you also have to prove that the injury is the fault of your employer. Or that you are not intoxicated or under the influence of illegal substances during the accident.

If you’re planning to file a workers’ comp claim soon but has a vague idea about how the process works, this quick guide will help.

Filing a Workers Comp Claim

On the part of the employee, the first step in the workers’ comp claims process is (obviously) filing a workers comp claim. In most states, injured workers can only qualify for workers compensation if:

  • they have workers comp insurance coverage
  • they are employees of the business and not contractors
  • the injury is work-related

If you satisfy the above conditions, you need to inform your employer about your injury as soon as possible. Some states require you to do this within 30 days or you’ll risk forfeiting your workers’ comp benefits. In emergency situations, you will have to be rushed to the emergency room. But in less grave cases, you can visit a doctor accredited by the insurance company to receive medical certification.

An injured worker filling out a workers compensation claim form.

After you’ve informed your employer, they should:

  • provide you with the proper reporting forms that you need to fill up
  • inform you about your workers’ comp benefits as well as the documents you need to submit
  • inform the insurance provider about your claim

Once the insurance provider has been made aware of your injury, they’ll evaluate your case. Using the medical and other evidence you submitted, they’ll either approve or deny your claim.

If your claim is approved, the insurance company will then contact you about the payment and settlement details. You can choose to accept the amount they’re offering or negotiate for a much more reasonable one.

In case your claim is denied, you can file ask them to review your case. If that doesn’t work, you can also take your case to court.

Receiving Your Workers Comp Benefits

If the insurance company approves your claim, you need to agree on a settlement amount. The settlement amount will include:

  • payment for your medical fees
  • a portion of your lost wages as dictated in your state’s workers comp laws

You can choose to receive your settlement amount in either lump sum or staggered payments. If you opt for the former, you won’t be able to ask for any more additional benefits in the future. You also cannot sue your employer for more compensation. Once the initial amount runs out, that’s it. Though in some states like New York, you may still claim medical benefits in the future.

What Happens When You Return to Work?

When you have reached maximum medical improvement (MMI), the doctor will issue a return to work order for you. You also need to inform your employer and insurance company that you’re returning to work.

Depending on the severity of your injury, the doctor may issue several work restrictions. Your employer must accommodate these restrictions as long as it does not cause them an undue burden. Otherwise, you can take them to court.

Returning to work may also mean that your workers comp benefits will stop. But if your disability is permanent, your employer may have to continue paying disability benefits.

Should You Hire a Lawyer?

Technically, you can process your workers’ comp claim on your own. But as mentioned above, insurance companies don’t like paying compensations. So unless you have a strong claim, getting your workers’ comp benefits won’t be that easy.

Remember that insurance companies, especially large ones, usually have a team of lawyers working for them. Hiring an experienced workers compensation lawyer like Victor Malca will level the playing field. He has already helped thousands of injured workers in Florida get the benefits they rightfully deserve. He can help you too. Call us now for a free consultation.


Victor Malca P.A. has over 25 years of litigation experience in Workers Compensation and Social Security Disability lawsuits. His experience and continued success in fighting for his clients puts among the most trusted workers’ compensation lawyers in Florida. Our area of expertise is in representing injured workers on compensation benefit cases and disabled individuals claim social security disability benefits.

Our unwavering advocacy for employee rights and privileges are recognized by our past clients across South Florida. Book a free consultation today.

Judy Ponio is a writer for Victor Malca LawAbout The Author

Judy Ponio is a writer for Victor Malca Law P.A. and enjoys helping people with questions about social security, workers compensation, and other serious matters involving people’s livelihood. She is not an attorney and her writing should not be considered legal advice.

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