NOTICE - USBenefits Insurance Services, LLC is not a Claims Administrator nor do we solicit business from individual consumers, and we are not affiliated with US Benefits / UMTA Trust (Oregon).

This is an updated version of an article USBenefits Insurance Services released in February 2022.

On occasion, employers and employees may be unsure if an injury or illness (injury) can be considered work-related. * The short definitions for the two insurance products are:

  • Workers’ compensation provides benefits to employees when they get injured at work or suffer a work-related illness. Further, this coverage is mandatory in most states.
  • Health coverage helps pays for non-work-related medical expenses.

It is common that, unless an injury occurs at work, the typical reaction is to utilize the employee’s health benefits. However, there might be circumstances where an injury might be work-related and not recognized accordingly. Why is this important? There are benefits in workers’ compensation that are otherwise not offered in the health benefits coverage. Workers’ compensation not only covers medical expenses but also covers:

  • Loss of wages for being off work due to the injury.
  • Disability if the injury causes any permanent disabilities.

Another difference with workers’ compensation for injured workers is that there are no copays, deductibles, or balance billing for the employee. The financial responsibility falls upon the insurance carrier or, if self-insured, the employer.

It’s the workers’ compensation “exclusive remedy” doctrine which makes this insurance coverage the injured worker’s sole remedy. While there are exceptions, and this is not absolute in all jurisdictions, in general, workers’ compensation is a “no-fault” system. What does this mean? An employee does not need to provide evidence of fault to receive the benefits outlined earlier. In exchange, employers are given immunity from lawsuits from the injured worker that involve compensatory damages outside what the workers’ compensation system offer or punitive damages.

It is believed that there’s a possibility there are a fair amount of health claims that might be eligible for Workers’ Compensation. If unsure which insurance coverage applies, we recommend you seek guidance from your attorney, claim administrator, or an insurance broker.

As a form of risk management to protect our customer’s interests, we at USBenefits Insurance Services’ take extra measures. We evaluate whether a claim falls within our coverage or workers’ compensation through our extensive claims management process.

*This article is not intended to persuade an employer or employee to pursue one form of insurance over another but rather to explain the benefits of workers’ compensation if the coverage is appropriate.

**It is important to note that only file a workers’ compensation claim if the injury is work-related or is suspected to be work-related. Filing a fraudulent workers’ compensation claim is a crime and punishable under the law. 

***Equally as important, by intentionally not filing (by disregarding the law, influencing the injured worker, etc.) a workers’ compensation claim if the injury is work-related or is suspected to be work-related may be deemed a crime.