West Virginia Workers Comp Claims: Eligibility, Filing and Appeals
West Virginia workers’ compensation laws provide benefits for most workers injured while working in the state of West Virginia. If you are injured or develop an occupational disease on the job in West Virginia, it's important for you to act quickly to preserve your right to workers’ compensation benefits.
The West Virginia Offices of the Insurance Commissioner (“Insurance Commissioner”) is responsible for administering workers’ compensation claims. Insurance companies, such as Sedgwick CMS and Wells Fargo, manage the claims on behalf of the Insurance Commissioner. But once your workers’ compensation claim has been accepted, your employer and their workers’ compensation insurance carrier will be your primary contacts during administration of your claim.
Employees Covered by West Virginia Workers' Comp
Not all individuals working in West Virginia are covered by the state’s workers’ compensation laws. Some workers, such as railroad workers and federal employees, are covered by separate statutes. West Virginia law also does not provide workers’ compensation benefits to volunteers, domestic servants, and independent contractors.
Injuries and Illnesses Covered by West Virginia Workers' Comp
As in many states, West Virginia workers’ compensation law provides benefits for both industrial injuries and occupational diseases. An industrial injury is a sudden, traumatic injury, such as a slip and fall resulting in a broken bone, that happens while working.
An occupational disease, by contrast, is a condition or illness that develops over time due to the distinct conditions of the workplace. One example is grocery store checkout clerks who get carpal tunnel syndrome. Occupational disease claims can also be the result of long-term exposure to toxins, like asbestos or other chemicals.
Your workers' comp benefits do not hinge on whether your claim is an injury or occupational disease. Instead, benefits depend on the severity of your impairment, the amount of wages you lost while you were out of work recovering, and whether you can return to work or have permanent disability.
Filing a Workers' Comp Claim in West Virginia
You should inform your employer of your industrial injury or occupational disease as soon as practically possible. Of course, don't delay receiving emergency treatment in order to inform your employer.
State law requires your employer to post a notice stating who to contact regarding a possible workers’ compensation claim. These notices are often posted in break rooms. You may be directed to inform other employees of your company or contacts at your employer’s workers’ compensation insurance carrier. If you are unable to determine who to contact, check with your human resources manager or direct supervisor.
Your employer, or its workers’ compensation insurance carrier, should provide you with a form entitled “Employees’ and Physicians’ Report of Occupational Injury or Disease – Form OIC-WC-1.” Your doctor should also have these forms and be able to help you to complete it. The form is available online at http://www.wvinsurance.gov/.
After you submit this form, your employer’s workers’ compensation insurance carrier will assign you a claim number and a claims adjuster. The adjuster will be responsible for administering your workers’ compensation benefits. Remember, the adjuster works for the insurance company, and so is not an advocate on your behalf. You should strongly consider hiring a workers' comp attorney, who can work directly with the adjuster to ensure your benefits are being administered properly.
Upon receipt of your claim for workers’ compensation benefits, the workers’ compensation insurance carrier will send you a written decision of whether your claim has been approved or denied. The letter will also state what medical conditions are covered by your claim.
Appealing a Claim Denial
If the insurance company denies your workers’ compensation claim, you have the right to dispute that decision with the West Virginia Workers’ Compensation Office of Judges. You must appeal the decision within 60 days of receipt of the written notice of the denial of your claim.
To appeal, you must submit a written protest of the claim denial to the Office of Judges and to your employer’s workers’ compensation carrier. The Office of Judges is located at PO Box 2233, Charleston, WV 25328. For more information, see our article on appealing a workers' comp denial in West Virginia.
West Virginia Workers’ Compensation Benefits
West Virginia requires workers' comp insurance companies to provide medical benefits and temporary and permanent disability benefits to workers with a covered injury or illness.
Your workers’ compensation insurance company will cover all of your medical expenses for treatment related to your industrial injury or occupational disease. This includes prescriptions, doctor visits, hospitalization, and physical therapy.
In the beginning of your workers’ compensation claim, you may choose any physician willing to accept payment from state-administered workers’ compensation funds. Your doctor will be able to tell you whether he or she treats patients with workers’ compensation claims. After you begin being treating by a particular physician, you must obtain prior authorization from your claim adjuster if you would like to switch to a different physician.
Temporary lost wage benefits. You are eligible to receive temporary disability benefits if your industrial injury or occupational disease prevents you from working four or more consecutive days. If your doctor certifies that you are physically unable to return to work for four or more days, your doctor will complete the necessary forms for you to qualify for these benefits.
Temporary total disability benefits are for lost wages while a worker cannot work at all during recovery from the industrial injury or occupational disease. The amount of compensation 2/3 of the injured workers’ average weekly wage, but is limited to 104 weeks. If you qualify for these benefits, you will receive compensation on a bi-weekly basis. These benefits continue until you are able to return to work again, up to the 104-week maximum.
Temporary partial disability benefits are available for workers that can return either part-time or at a lower paying job while recovering. The worker can receive up to 70% of the difference between the current wage and the average weekly wage at the time of the injury. These benefits are rare, but if you believe you qualify and you are not receiving these benefits, you should talk to a workers' comp attorney.
Permanent disability benefits. Should your industrial injury or occupational disease result in permanent physical impairment, you will be eligible for additional benefits. Once you have reached maximum medical improvement, meaning there is no additional treatment that will help improve your claim-related conditions, your doctor will assess whether you have any permanent disability. If so, your doctor will determine a percentage of disability. The insurance carrier may also require you to attend an independent medical examination, during which the examiner will assess your level of permanent impairment.
Permanent total disability benefits are calculated using 2/3 of the injured workers’ average weekly wage. The amount of permanent partial disability benefits an injured worker can receive is based on the daily rate; four weeks of weekly payments will be made for each percent of disability. These benefits are paid monthly, and begin the day after the last temporary disability benefit was paid. Retroactive permanent total disability payments are made at one time in a lump sum.
Your claims adjuster may refer to you a case management professional. This individual will be responsible for assisting in your efforts to return to work. This may include lighter duty or modified work at your current employer, or retraining for new job skills for your current employer or employment elsewhere.
When to Talk to an Attorney
A workers’ compensation attorney can represent you if your claim is denied, to help you get it accepted. Even if your claim is accepted and the insurance company offers you a settlement for permanent disability, you'll want to talk to an attorney to see if the settlement offer is fair or if the attorney could negotiate for more on your behalf. This is especially important if you've been seriously injured. To find a local workers' comp lawyer, visit our workers' compensation lawyers page.