Recent Traumatic Events

Workers’ compensation claims are usually pretty straightforward. Here’s one that’s not.

An employee reported that he injured his back at work. The employer (a food/agriculture business) and its insurer accepted the claim, paid him for lost time and medical treatments, including lumbar fusion. But six months later, when the employee stopped complying with his medical care, the case was sent to Gregg M. Porter, of Savell & Williams, in Atlanta.

“We then discovered that the employee had a history of lumbar issues, some as far back as 20 years, and some very recent, for which he sought medical treatment just a few months before the alleged accident,” Porter remembers. “Of note, he specifically denied in his deposition that he had any lumbar medical treatment or issues prior to his alleged accident. It was also discovered that the employee lied on his post-hire medical questionnaire specifically denying prior lumbar problems and medical treatment.”

The claimant’s lawyers eventually dropped any claim for future benefits and the case was turned over by the employer and insurer to the enforcement unit at the State Board of Workers’ Compensation. “After the fraud was discovered, I asked the employer what he wanted, and he said, ‘I want him to go to jail,’” Porter says. And that’s what happened. The claimant was prosecuted for insurance fraud under the Workers’ Comp Act and spent several years in prison.

This case, though extreme, shows why legal representation can be so important in workers’ comp claims. Every state creates its own rules; in Georgia, it is a no-fault system designed to provide specified benefits for work-related injuries for any reason. “It can be a traumatic event—a warehouse pallet falls on you, you’re run into by a forklift—or a repetitive trauma like carpal tunnel syndrome,” Porter says. 

The “ultimate purpose” is to ensure that someone injured on the job can return to work, says Darrell Sutton, of Sutton Law Group in Marietta. Workers’ comp insurance provides three basic benefits: coverage for any medical treatment needed for the injury; weekly compensation while the worker is unable to work; and partial permanent compensation if there is some reduction in use of a body part. 

“For example, say I had a knee injury, and after treatment it’s only about 90% as good as it was before the injury. It would compensate me for that loss if it had been work-related,” Sutton says. 

Lost-wage compensation is worth two-thirds of wages—capped at $800 a week, Porter adds. Permanent impairment compensation is a calculation based on the rate of impairment: say, 10% as in Sutton’s example, times the number of weeks specified in the code, times the workers’ comp rate. This is also capped at $800 a week. There are no “pain and suffering” allowances. 

There are exclusions, of course. If you’re injured on the job but intoxicated or in violation of company rules or regulations, that would not be covered. If you’re injured taking a personal detour while driving for work, you’re not covered. “In Georgia there are also exceptions for having a heart attack or stroke [on the job],” Sutton says. “The presumption is it doesn’t count unless you can provide some affirmative medical evidence proving otherwise.” I.e., prove it was brought on by the work itself.

Any Georgia business with three or more employees is required to have workers’ comp insurance, but the cost depends on the type of business. “If it’s an office business, it’s not costly. 

If it’s a manufacturing facility, it costs a lot,” Porter says. Like auto insurance, your personal history affects your premium. 

Sutton says business owners and decision-makers should “remain mindful that decisions about handling a workers’ compensation claim should always be business decisions. Where I have seen clients encounter trouble is when they make those decisions based upon emotion rather than upon objective monetary calculations.”

He also stresses that a WC policy will invariably pay for itself over time. 

“It’s cheap relative to other insurance, and it can save you even if a claim is not legitimate,” Sutton says. “Across my 20 years of practice I have time and again represented businesses that decided to save money on the front end by not purchasing workers’ compensation insurance, only to pay multiple times the cost of that premium when a workers’ claim is filed and they have to defend against it. The attorney’s fees associated with defending a claim nearly always exceed the workers’ compensation insurance premium that the business avoided—not to mention the cost to resolve the claim. Both would have been paid by an insurer had they purchased the insurance in the first place.”