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Some Georgia workers’ compensation claims turn out to be more than just a workers’ compensation claim. In a recent case, a court considered whether an employee could bring a fraud claim against his employer after the employer denied his workers’ compensation claim.

GavelIn that case, according to the facts alleged in the complaint, the employee needed to move bags of concrete mix while he was working at a public transportation company. Since he had previously injured his back, and the concrete mix bag weighed 90 pounds, the employee asked his supervisor for permission to break down the bag into lighter bags or to have another employee help him lift the bag. The supervisor refused and ordered him to lift the bag.

The employee picked up the bag, immediately felt pain in his back, and partially collapsed. His supervisor asked him why he dropped the bag, and he told him it was because he injured his back when he lifted the bag. The employee filled out a workers’ compensation claim form the next day. His supervisor later filled out a work report, in which he wrote that he did not witness the employee’s injury. The supervisor was later deposed and testified that the employee did not request an accommodation and that he did not see him injure himself. The employer subsequently denied the employee’s workers’ compensation claim.

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In some Georgia workers’ compensation cases, the consequences of the workplace injury are tragic. In the event of the death of a worker, the worker’s family is generally entitled to death benefits under Georgia’s Workers’ Compensation Act to ease the financial burden on the family. These benefits normally include burial expenses, as well as weekly ongoing compensation for the employee’s dependents.

Movie CameraUnder current law, for a compensable work injury, the employer must pay the reasonable expenses of the employee’s burial, up to $7,500. In addition, the worker’s dependents are entitled to weekly compensation of two-thirds of the worker’s weekly income, up to a maximum of $575 per week. Dependents normally include the worker’s spouse, children, and dependent stepchildren.

However, employers often dispute that a claim is compensable to avoid paying death benefits under the Act. The employer may claim that the worker was not an actual employee or that the injury did not take place on the job. A person claiming benefits must show that the death resulted instantly from an accident arising out of and in the course of employment, or that during a period of disability caused by an accident, the worker died as a result.

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In some Georgia workers’ compensation cases, disputes arise not over the accident itself but over which treatments are covered under workers’ compensation benefits. In one recent case, the employer disputed whether a knee replacement surgery two years after the work injury was required because of the work injury or because of a preexisting condition.

SurgeryIn that case, after an electrician slipped on the step of a truck at work, his employer accepted that the injury to his knee was compensable for workers’ compensation benefits and authorized treatment with an orthopedic surgeon. The same surgeon had seen the employee about two years before the work injury and noted significant pain, which suggested either arthritis or a preexisting tear, but he did not find a need for treatment at the time. After the work injury, the surgeon found significant preexisting left knee arthritis. The employee had more pain behind his left kneecap and suggested a tear in his medial meniscus. The surgeon recommended left knee surgical repair, and the employer authorized the repair.

About two years after the work injury, and after the surgeon had operated on the employee, the surgeon diagnosed the employee with osteoarthritis of his left knee and a left knee medial meniscus tear, recommending a left total knee replacement. He later testified that the employee’s preexisting condition was the major contributing cause of the need for the knee replacement. The employee requested authorization for the knee replacement, but the employer asserted that it was not compensable. The employer argued that the employee’s arthritis was a preexisting condition and that the knee replacement was required because of the condition, and the work injury was not the major contributing cause of the knee replacement.

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In some Georgia workers’ compensation cases, the plaintiffs have to consider not only workers’ compensation claims but also separate claims against third parties. In a recent case before one state’s supreme court, the court considered whether the plaintiff was entitled to workers’ compensation benefits after the plaintiff had already settled a claim against a third party.

Utility PoleIn that case, the plaintiff injured his neck and shoulder while he was working as a utility technician. He filed a workers’ compensation claim, and his employer accepted the claim as compensable. When he was supposed to return to work, the plaintiff was still in too much pain, and his treating doctor informed him that he would provide him with an out-of-work note that he could pick up from the office.

On his way to pick up the note, the plaintiff was in a car crash and suffered a traumatic brain injury. The plaintiff’s wife contacted the plaintiff’s supervisor and explained the circumstances of his car accident, and the plaintiff later discussed it with his supervisor and his safety manager. The plaintiff hired a separate attorney for a personal injury claim related to the car crash. His personal injury attorney told his health insurance company that he was not “at work” when he was in the car crash, and therefore the health insurance company should cover his injuries. He then settled his personal injury claim for around $45,000.

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The first question in almost any Georgia workers’ compensation case is when the claim has to be filed. This is because statutes of limitations and statutes of repose can limit the time during which an individual can file a claim.

Alarm ClockIn a recent case, one state’s supreme court considered the constitutionality of a statute limiting the time to bring a workers’ compensation claim. Under that state’s workers’ compensation act, a provision limited the time an injured worker has to prove a claim. The statute stated that an employee attempting to prove a workers’ compensation claim has to show that the employee was owed compensation within 12 years of the date of the accident.

In that case, two employees had separately filed workers’ compensation claims and had received benefits, and in both cases, the employees’ conditions worsened later. Both employees filed claims for additional benefits to receive permanent total disability benefits more than 12 years after the workplace accidents had occurred. The employees argued the statute was unconstitutional under that state’s constitution.

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Often in Georgia workers’ compensation cases, workers are focused on replacing their income while they are injured. However, workers may forget that they may be also entitled to rehabilitation services. In a recent case, one state’s supreme court recently approved a two-year training program for an injured worker to pursue a new career.

Graduation CapThe employee injured his arm at work, and the court later ruled that the employee was entitled to a vocational rehabilitation evaluation. The employee and the employer agreed on a vocational rehabilitation counselor, who created a rehabilitation plan for the employee. In the employee’s case, he could not return to the same employer because the employer did not have suitable work available for him with his injury, and there were no viable opportunities of similar pay with other employers.

The rehabilitation counselor recommended that the employee participate in formal training that would lead to employment in another career field. She suggested that he obtain a two-year associate’s degree in agriculture at a community college, based on his interest in agriculture. However, the court’s vocational rehabilitation specialist disagreed with the plan. The specialist believed the formal training was not necessary or appropriate. The specialist reasoned that there were job openings of similar pay to what he would make after the training program and that formal training was not necessary. The counselor explained that the employee’s goal was to be a supervisor or manager, and typically training is required for those positions. The employer petitioned the court to eliminate the treatment, and the employee petitioned the court to approve it.

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One accident can result in a number of claims and potential benefits. For example, as as one news source explains, if a person gets into a car accident at work, not only may there be a Georgia workers’ compensation claim, but also the incident may give rise to a negligence claim, a disability claim, an FMLA claim, and a medical malpractice claim, among others.

Construction SiteThe Difference Between Workers’ Compensation Claims and Personal Injury Claims

In a personal injury claim, a plaintiff has to show four elements:  duty, breach, causation, and damages. This means proving that the defendant owed a duty to the plaintiff, failed to meet the duty to act reasonably under the circumstances, and caused the plaintiff damages.

In contrast, in a workers’ compensation claim, a claimant does not need to show that the employer owed the claimant a duty, nor that it breached that duty by failing to act reasonably. In other words, it does not matter who is to blame for the injury. Instead, the claimant must only show that the injury occurred while in the course of employment and that it was related to the employment. The issue then becomes the extent of the claimant’s disability.

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In a recent Georgia workers’ compensation case, the Georgia Supreme Court recently issued a decision clarifying what an employer has to show in resolved work-related injury aggravation cases. The Georgia Supreme Court considered whether an employer has to show suitable employment is available in order to stop paying workers’ compensation benefits if it has already shown that a work-related aggravation of an injury is no longer the cause of the employee’s disability.

Knee BraceThe Facts of the Case

In that case, the employee injured his right knee when he was working at a youth detention center. He had three knee surgeries and eventually settled his workers’ compensation claim about a year later. As part of the settlement agreement, the employee admitted that he was partially disabled, his condition would not improve, and he would not be able to perform the same type of gainful employment on a regular basis in the future. He was given a 20 percent permanent impairment rating and was out of work for about four years.

The employee then applied for a job as a meter reader. When he applied, the employee did not disclose information that would have demonstrated that he was not physically capable of performing the job. Instead, the employee stated that he was physically capable of performing the job functions, including standing and walking. The employee got the job, and while he was working about two years later, he stepped in a hole and re-injured his knee.

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When an injured worker files a Georgia workers’ compensation claim, the first step is determining if the injury is going to be accepted by the employer. If the employer contests the fact that the injured employee was covered, the employee may need to appeal that decision to a review board and eventually a court of law.

ClassroomHowever, in situations in which an employer accepts that an injury was covered, the next questions involve determining what constitutes the employee’s compensation. This is important because whatever the employee’s compensation is determined to be will affect the weekly workers’ compensation benefits available to the employee.

Obviously, an employee’s wages are the bulk of their compensation. However, there may be other benefits a workplace offers that can be considered part of an overall compensation package. For example, a recent workers’ compensation appellate opinion held that free-tuition benefits were part of an employee’s compensation.

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If a Georgia worker is not honest about their condition, it can not only take away their right to workers’ compensation benefits but could also land them in jail. However, in a recent case from one state, a court found that a worker might still be entitled to benefits even after a criminal conviction for workers’ compensation fraud.

NewspaperIn that case, the employee was working at a car company and slammed the trunk of a car on his hand accidentally. He crushed one of his fingers and claimed he could not continue to work, due to pain in his hand and shoulder. He filed a workers’ compensation claim in California and received benefits as a result. The workers’ compensation provider later hired a private investigator to monitor the employee. The investigator filmed the employee leaving three doctor’s visits. Video showed the employee taking off his sling, using his hand to get in and out of his car, using his hand to drive, and using his hand to carry a bag of groceries. The workers’ compensation provider notified the district attorney, who then began their own investigation.

In certain circumstances, under that state’s law, if a worker is convicted of fraud in obtaining workers’ compensation benefits, the worker cannot recover benefits arising from the fraud. However, if a worker is able to show that he or she was entitled to benefits independent of fraud, benefits can still be awarded. In this case, the court found that there was evidence that the worker had suffered a compensable injury and was entitled to benefits independent of the fraud. Therefore, even though the worker eventually was convicted of a misdemeanor crime, the court found he was entitled to benefits as a result of his work injury.

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