Workers’ Compensation Glossary of Terms

Workers’ compensation glossary of terms

• Attorney for employee/claimant and attorney for employer/insurer. Many workers benefit from hiring an attorney to represent them during a workers’ compensation claim. Not only may an attorney be of assistance if the employer or insurer refuses to pay, but they also determine if justice should be pursued beyond the workers’ compensation process. Of course, the employer and insurer may also have legal representation.
• Average weekly wage (AWW). Every income benefit in a Georgia workers’ compensation case ties back to the average weekly wage. The AWW sets the size of your weekly benefit check, so getting it calculated correctly matters from the first day of your claim.
  
  O.C.G.A. § 34-9-260 provides three ways to calculate it. The standard method looks at the 13 weeks you worked immediately before your injury. Your employer fills out Form WC-6, listing gross wages for each of those 13 weeks. Divide the total by 13, and that number becomes your AWW.
  
  If you didn’t work substantially the whole 13-week period, a second method compares your wages to those of a similar employee doing the same job. A third method, based on a full-time weekly wage, applies when neither of the first two works.
  
  AWW calculations go wrong often. Overtime, bonuses, commissions, and wages from a second job doing similar work can all factor in. Insurers routinely omit them. A miscalculated AWW can underpay you on every weekly check for the entire life of your case.
• Board claim number. After you file a claim with the SBWC, it will issue you a 9-digit case file or claim number.
• Catastrophic. Workers’ compensation benefits are limited in Georgia to 400 weeks of payment. The exception to this rule is if an injury is deemed “catastrophic.” A catastrophic injury in Georgia is defined as any one of the following injuries:
• A spinal cord injury involving severe paralysis
• Amputation of an arm, hand, foot or leg
• Severe brain or closed head injury
• Total industrial blindness
• Second or third degree burns over 25% of the body, or third degree burns to 5% or more of the hands or face
• Any other injury that prevents the employee from being able to perform their prior work in substantial numbers within the national economy for which they are otherwise qualified.
• Controvert. To controvert means the employer or its insurer formally disputes your right to workers’ compensation benefits. When a claim is controverted, the insurer refuses to pay, and you have to request a hearing before an Administrative Law Judge at the State Board of Workers’ Compensation to establish your entitlement.
  
  Under O.C.G.A. § 34-9-221, the insurer files a Form WC-2, Notice to Controvert Payment of Compensation, to put the dispute on record. A controverted claim does not mean you’ve lost. It means the issue goes before a judge, who weighs the evidence from both sides and decides whether benefits are owed. You should have an attorney representing you before any hearing.
• Denied claim. A denied claim and a controverted claim describe the same basic situation: the insurance company is refusing to pay. Some practitioners use these terms interchangeably. In practice, when a claim is denied, the insurer has concluded that your injury is not compensable under the Georgia Workers’ Compensation Act. The denial might challenge the injury itself, dispute that it happened at work, or contest your entitlement to a specific benefit.
  
  A denial is not the end of your case. Denials are overturned regularly through the hearing process at the State Board. The insurer’s denial is simply the beginning of a dispute that an administrative law judge ultimately resolves.
• Dependency benefits. In Georgia, if a work-related death occurs, the workers’ compensation law provides benefits to the dependents of the deceased worker.
• First date disabled. In Georgia, the date of disability is the first day the employee is unable to work a full day.
• Indemnity benefits. This is the term commonly used for wage replacement or “lost income” benefits. There are 2 main types of indemnity benefits: temporary total disability (TTD) benefits and temporary partial disability (TPD) benefits. An injured worker is eligible for this benefit if the authorized treating physician takes them out of work for more than 7 consecutive days, if the authorized treating physician has placed them on work restrictions which their employer cannot meet, or if they are on work restrictions and their employer cannot offer them the same amount of hours or the pay rate decreases with the new job so they earn less than they received while working. In Georgia, the maximum amount of weekly indemnity benefits changes yearly and there is no cost of living increase over time.
• Insurer/self-insurer. Georgia employers purchase workers’ compensation insurance in the private market from an insurance carrier or agency that is licensed to write that type of policy in the state. Alternatively, if an employer meets certain specifications, it can petition the SBWC to be self-insured. The SBWC and the Georgia Self-Insurers Guaranty Trust Fund evaluate each applying employer to determine if it qualifies for self-insurance. The SBWC then issues a 5-digit ID number to each employer.
• Jurisdiction. Jurisdiction is the venue in which the case can be brought. This is important because workers’ compensation laws are specific to each state. For example, in some states, indemnity benefits can be stopped when an individual reaches maximum medical improvement (MMI). However, this is not the case in Georgia so it is important to bring a claim in a jurisdiction that most benefits the injured worker.
  
  There is jurisdiction in Georgia if either of the following 2 conditions are met:
  
  
  1. The accident took place in the state of Georgia.
  2. The contract of employment was made in Georgia and the individual resides in Georgia, or the employer is in Georgia and the contract for employment wasn’t for work exclusively outside of Georgia.
• Light duty work restrictions. These are restrictions placed on an injured worker by the authorized treating physician. They specifically relate to the individual’s injured body part and place restrictions on the work they can perform. It is important to provide the work restrictions that the authorized treating physician places on you to your attorney immediately. Just because an employer may not have an existing job within these restrictions doesn’t mean that they will not create a special one for an injured worker.
• Maximum medical improvement. When the authorized treating physician determines that an injured worker has healed as much as they are going to, they have reached maximum medical improvement (or MMI). This doesn’t necessarily mean that the injured worker is fully healed. It merely means that the authorized treating physician believes they have plateaued and will not get better. In some states, this means that indemnity benefits can be suspended, but not in Georgia. When an individual reaches MMI, they are entitled to a permanent partial impairment (see PPD below) rating on top of whatever indemnity benefits they are eligible to continue to receive.
• Medical benefits. Georgia workers’ compensation laws require payment for all necessary and reasonable medical treatment that is related to a work injury or illness.
• Notice of claim only. Your first filing of the WC-14 can be notice of claim only.
• Panel of physicians. Georgia law requires employers to post a list of authorized physicians from which an injured employee must choose a treating doctor. This list is the panel of physicians. Under O.C.G.A. § 34-9-201, the panel must contain at least 6 physicians, at least 1 of whom must practice orthopedic surgery, and no more than 2 can be industrial clinics.
  
  Your choice of authorized treating physician has major consequences. That physician controls your work restrictions, your return-to-work status, and ultimately your PPD rating. If your employer failed to properly post a panel or never told you of your right to choose from it, you may be entitled to be treated by a physician of your own choosing at the employer’s expense.
• Permanent partial impairment rating. This means a disability which is partial in character but permanent in quality, resulting in the loss of a portion of functionality of a body part. The state legislature of Georgia has established a formula to compensate injured workers for the loss of this functionality. The formula is the workers’ compensation rate multiplied by the impairment rating multiplied by the body part. Each body part has been assigned a value by the legislature, ranging from 300 weeks to the body as a whole, all the way to 20 weeks for loss of any toes (besides the big toe).
• PPD. Permanent partial disability benefits, also called PPD benefits, compensate you for a permanent physical impairment once your condition has stabilized. Unlike TTD and TPD, which replace lost wages, PPD pays for the physical damage itself, regardless of whether you’re actually earning less money now.
  
  A physician assigns you a percentage impairment rating to the affected body part. Georgia law uses a schedule that assigns a fixed maximum number of compensable weeks to each body part. Your PPD award equals your impairment percentage multiplied by those maximum scheduled weeks, paid at two-thirds of your AWW up to the applicable maximum rate.
  
  PPD ratings are frequently disputed. The rating assigned by the authorized treating physician and the rating from an independent medical examiner can differ significantly, and that difference can be worth thousands of dollars in your case.
• Request for catastrophic designation. Many work injuries or illnesses are short-term and, following recovery, the employee can return to full employment. However, sometimes an employee may suffer a catastrophic injury or illness that results in a loss of function or permanent disability. Georgia law provides for specific benefits if a catastrophic designation is granted under a workers’ compensation claim.
• Request for mediation/notice of claim. The third choice at the top of the WC-14 form is a request for mediation. A mediator is a neutral person who works with the parties to help reach a resolution in the dispute. The mediator may offer suggestions and assistance, but does not make a decision. The parties have to agree on the final decision. Mediation in workers’ compensation cases is voluntary.
• Request hearing/notice of claim. If your benefits are denied, you can request a hearing by checking this box at the top of the WC-14 form. The hearing takes place in front of a workers’ compensation judge. The judge requests information from both parties. You can present your case and medical records to the judge, present other witnesses to support your case, and be cross-examined by the lawyer representing your employer or their insurance company. The insurance lawyer may also present paperwork and witnesses. The judge will not release a decision at this time. Both parties draft closing briefs, which summarize their positions, and present them to the judge.
• TPD. TPD benefits (or temporary partial disability benefits) apply when you’ve returned to work but earn less than you did before your injury because of your medical restrictions. You may have gone from full-duty labor to light-duty work, or from a 40-hour week to 20 hours. The gap between what you earned before and what you earn now is what TPD addresses.
  
  The formula for TPD benefits is two-thirds of the difference between your pre-injury AWW and your actual post-injury weekly earnings, up to the maximum TPD rate in effect on your date of accident.
  
  If you earned $900 per week before the injury and can only earn $400 per week now, TPD pays roughly two-thirds of the $500 difference, approximately $333 per week. TTD and TPD are mutually exclusive. You receive one or the other at any given point in your case, not both.
• TTD. TTD benefits refer to temporary total disability benefits. These are paid when your authorized treating physician takes you completely off work because of your injury. “Temporary” means your condition is expected to improve. “Total” means you have no work capacity at all.
  
  The weekly TTD rate is two-thirds of your AWW, up to the maximum rate set by the State Board of Workers’ Compensation for your date of accident. In a non-catastrophic claim, a cap limits the total number of weeks you can receive TTD.
  
  Keep in mind that Georgia workers’ compensation pays nothing for the first 7 days of disability unless you miss more than 21 days of work. Once you cross the 21-day threshold, those first 7 days become payable.
• WC-14 notice of claim. This is the form that is administered by the State that you can obtain from the SBWC, find online and complete. It is 1 page. To file a claim, you need to complete Form WC-14, file it with the State Board of Workers’ Compensation, send a copy to your employer and send another copy to your employer’s workers’ compensation insurance carrier.