Workers' Compensation law provides three types of benefits for a person who is injured while performing work-related duties.

1. The employee is entitled to receive medical treatment for the work-related injury and does not have to pay for that treatment. The employer or insurer makes payment. But remember that the employer has the right by law to select the physician. So if you seek treatment that has not been authorized, you may have to pay for that treatment yourself.
2. Temporary total disability (TTD) is compensation for the time the doctor says you are unable to work because of the injury. You will not receive TTD benefits for the first three regularly scheduled workdays you are off unless you are off longer than 14 calendar days. Those benefits are calculated at two-thirds of your average weekly wage not to exceed a maximum rate set by the legislature. Your average weekly wage is determined according to how your wages are fixed, whether by the week, by the month, by the year or by some other method, such as amount of sales. Temporary total disability benefits cease when the doctor says you are able to return to work. Although those wages are only two-thirds of your average wage, it is important to remember they are tax-free.
3. Compensation for a permanent disability. Once a doctor has done all he or she feels can be done medically to help you, and you are not as physically able as you were before the injury, then you have a disability. And if there isn't anything else the doctor can do to make you any better, your disability will be "permanent," meaning you will suffer the effect of the injury from that point on. That disability will either be "total" meaning you are unable to perform any work, or "partial" which means you are able to work but there are limitations or restrictions as to what you are able to do. If you are determined to be permanently and totally disabled, your benefits will continue for the rest of your life. If your disability is a permanent partial disability (PPD), the legislature has established a formula to convert that disability into a dollar amount. The maximum weekly wage amount for a permanent partial disability is less than the maximum for the temporary total disability because the disability is partial instead of total. Compensation is for the disability only. The law does not provide compensation for pain and suffering.

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Whether or not the employer believes the injury is work-related, prompt reporting to the employer is necessary and required. Employees should ensure their rights to benefits by providing the employer a written notice of the injury, no matter how minor. To do that the employee must:

• Report the injury to your supervisor as soon as possible.
• Tell your supervisor everything you can about the injury - what, where, when and how it happened.
• Get prompt medical care for the injury.
• Inform your employer about your medical condition and when you can return to work if the injury caused you to miss work.

An employee who fails to notify the employer of a work injury within thirty days may jeopardize his or her ability to receive workers' compensation benefits.

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Your employer should make sure you receive immediate medical attention to treat the injury. The employer must report the injury to the insurance company, or the administrator if self-insured, within five days of the date of the injury or within five days of the date on which the injury was reported to the employer if that is later. The insurance company or administrator then reports the injury to the Division of Workers' Compensation.

If your employer denies that the injury is work-related, you should determine through the employer if the injury has been reported. Then contact the Division's Dispute Management Unit at (573) 526-4951.

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Medical benefits for an employee who suffers a work-related injury include medical treatment to cure the injury. You do not have to pay for any portion of the treatment. The employer has the right to select the health care provider, such as the doctor, hospital and clinic. Often, the employer allows the insurance company or third party administrator to make this selection. If you have problems with a health care provider, let your employer know and request a change be made. The employer is not required to make a change, but the request will sometimes result in a referral to a different provider or better treatment. The employer has the final say to the insurance company in the selection of the health care provider

You can select your own medical provider at your own expense. If your employer refuses to provide medical treatment, you may receive reimbursement for any medical treatment that is reasonable and necessary to cure the work-related injury. If possible, you should obtain a written refusal to provide medical treatment from the employer.

You should not be billed for medical treatment you receive for a work-related injury, unless you selected the health care provider. If you are, you must notify the health care provider that this is a workers' compensation injury, with notice of the name of the employer, the name of the insurer, if known, the general nature of the injury, if known, and if a claim has been filed, the claim number, if known. This notice must be in writing and should be sent by certified mail.

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In most circumstances, if you are off work because of a work-related injury, you are eligible to receive temporary total disability (TTD) benefits to replace your lost wages. You are eligible if you have missed more than three regularly scheduled workdays. These are regularly scheduled workdays of your employer. If you miss more than two weeks, these first three days, referred to as the waiting period, are paid to you.

The amount you receive is based on two-thirds of your average weekly wage; also know as the compensation rate. The statutory maximum for the compensation rate is 105 percent of the State Average Weekly Wage. For injuries that occur on or after July 1, 2003, the maximum is $662.55. For example, if you earn $300.00 per week, your TTD benefits would be $200, that is two-thirds of your average weekly wage. If you earned $1,100.00 per week, two-thirds of your average weekly wage would be $733.26, so your TTD benefit would be limited to $662.55. The maximum amount is determined by the date of injury.

Your average weekly wage is computed based on your gross wages. If your wages are fixed by the month, multiply your monthly gross wages by 12 and divide that total by 52 to determine your average weekly wage. If your wages are fixed semimonthly, multiply your gross wages by 26 and divide that total by 52 to determine your average weekly wage. If your wages are fixed weekly, that is your average weekly wage. If your wages are fixed by the hour or some other method such as sales output, take a total of your gross wages for the last thirteen weeks and divide that total by thirteen to determine your average weekly wage. If none of these situations apply to you, please call (800) 775-2667 during business hours, 8 a.m. to 5 p.m. Monday through Friday, for further information.

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If your employer, or the insurance company, wants to settle your case, you should have finished medical treatment and have been released to return to work by the doctor. If you have not finished medical treatment, have recently had major treatment such as surgery or if you are still on work restrictions, your case is not ready to settle. If the work restrictions are permanent, the doctor should have advised you of this.

The disability benefit that is paid for any permanent residual effect of your injury is called permanent partial disability. This is a lump sum benefit that is paid to you after the injury has been treated and you have recovered to the fullest extent possible. The permanent partial disability benefit, often called PPD, is paid to compensate you for that permanent residual effect of the injury. These payments are based on a weekly schedule for various body parts, the rating of that permanent injury and your average weekly wage.

In order for your case to be settled, the doctor should rate your work-related injury. This rating is the doctor's opinion on the permanent effect of the injury. It is usually given as a percentage of a body part such as an arm, leg or finger. A back or neck injury is rated as a body as a whole injury. Depending on the body part affected by your injury, there are a number of weeks that are set out for that body part. For example, the leg at the hip is rated at 207 weeks, the arm at the shoulder at 232 weeks, the index finger at the first knuckle at 45 weeks, and the body as a whole at 400 weeks.

Your compensation rate is calculated the same way as the temporary total disability benefit, that is two-thirds of your average weekly wage. However, the maximum limitation is lower at 55 percent of the State Average Weekly Wage, or since July 1, 2003, $347.05. The maximum amount is determined by the date of injury.

Your average weekly wage is computed based on your gross wages. If your wages are fixed by the month, multiply your monthly gross wages by 12 and divide that total by 52 to determine your average weekly wage. If your wages are fixed semimonthly, multiply your gross wages by 26 and divide that total by 52 to determine your average weekly wage. If your wages are fixed weekly, that is your average weekly wage. If your wages are fixed by the hour, or some other method such as sales output, take a total of your gross wages for the last thirteen weeks and divide that total by thirteen to determine your average weekly wage. If none of these situations apply to you, please call (800) 775-2667 during business hours, 8 a.m. to 5 p.m. Monday through Friday, for further information.

Let's work through an example. Assume you have an injury to your wrist. The wrist is rated at the 175-week level. So if the rating is 10 percent, your settlement will be based on 10 percent of 175 weeks or 17.5 weeks. Assume your average weekly wage is $300.00. Your compensation rate (two-thirds of your average weekly wage) is $200.00. The compensation rate of $200.00 times the 17.5 weeks comes to $3,500.00. The total PPD benefit would be $3,500. Of course, an administrative law judge is the final decision maker on the appropriateness of the rating and the average weekly wage. So, just because the employer or insurance company has offered a settlement proposal, this does not mean your case is settled. You must appear before Division staff for final approval of the settlement.

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Under the workers' compensation law, when an employee is required to submit to medical examination or medical treatment at a place outside of the local metropolitan area from the employee's principal place of employment, the employer's workers' compensation insurance carrier should reimburse the employee for reasonable and necessary expenses, including mileage. The mileage rate for each case is determined by the rate on the date of the injury. If the injured employee resides outside the state of Missouri and is employed by an employer located in Missouri, the employer has the option of selecting the provider within one hundred miles of the employee's residence, place of injury or place of hire.

If there is a dispute as to what expenses are owed by the employer, the issue should be presented to the administrative law judge. However, the employer is not required to pay transportation costs for a greater distance than 250 miles each way from the place of treatment.

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Under the Missouri workers' compensation law, if an employee sustains an injury of sufficient severity he or she may receive vocation rehabilitation services that are reasonably necessary to restore the employee to suitable, gainful employment, if the employer/ insurer authorizes the rehabilitation services. If the employer determines that there had been a loss of suitable gainful employment, the employer may retain the services of a rehabilitation practitioner. In other words, vocation rehabilitation is strictly voluntary on the part of the employer. The Division may notify the employer that the injured employee may require vocation rehabilitation. Examples of an injury of sufficient severity as determined by the treating physician are traumatic injury to the spinal cord, severe burns, serious head injury, loss of sight in one of both eyes, loss of hearing in both ears or loss in serious head injury, loss of sight in one or both eyes, loss of hearing in both ears of speech or severe mangling, crushing, amputation or nerve impairment of a major extremity.

Contact the Department of Elementary and Secondary Education, Division of Vocation Rehabilitation, Central Office at (573) 751-3251 for information regarding eligibility to receive vocational rehabilitation services.

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The Second Injury Fund is designed to compensate an injured employee when a current work-related injury combines with a prior disability to create an increased combined disability. The basic concept is the whole is greater than the sum of the parts. For example, if an injured employee has a 15 percent disability from the prior injury, and the combined disability is 40 percent, the Second Injury Fund pays for the increased disability. The formula for calculating the Second Injury Fund benefits depends on each case.

An injured employee must have a permanent preexisting disability to trigger liability of the Fund. The prior disability must be "of such seriousness as to constitute a hindrance or obstacle to employment." In order for an employee to recover from the fund, certain minimum limits must be met.

The Fund is also responsible for paying medical bills of injured employee's when the employer fails to insure its workers' compensation liability. In addition, if the employee is killed, burial expenses and death benefits in the form of weekly payments to the surviving spouse of dependents of the employee are paid from the Fund if the employer is uninsured.

The Fund also provides benefits to injured employees who are undergoing physical rehabilitation. To qualify for these benefits, the employee must be seriously injured and be receiving therapy at a facility certified by the Division. If the injured worker qualifies, he or she will receive $40 per week for up to 20 weeks for rehabilitation.

The last benefit from the Second Injury Fund is second job wage loss benefits. The benefit applies to injuries that occurred after August 28, 1998. The employee must be injured on the job with the first employer. If the employee is unable to work at a second job as a result of the injury, these benefits may be claimed from the Second Injury Fund.

Only the employee, the employee's attorney or the employee's dependent can make a claim against the Second Injury Fund. Claims for permanent total and permanent partial disability benefits, uninsured employer medical cost, or death benefits are made by filing a Form 21, Claim for Compensation form, with the Division.

For more information call Division toll free at (800) 775-2667.

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The treating doctor may release the employee to return to work with light duty or modified duty restrictions. The employer may offer an employee a job that would accommodate the light duty restrictions. Depending upon the number of hours the employee is able to work on light duty restrictions, and the wages paid by the employer, the employee may be entitled to receive temporary partial disability benefits.

The temporary partial disability benefit consists of two-thirds of the difference between the employee's average earnings prior to the accident, and the wages that employee earns during the period of disability, not to exceed the maximum rate set by the legislature.

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If the injury occurs on or after August 28, 2005, the new definitions will apply. Primarily, an employee will have to show that work was "the prevailing factor" in causing both the resulting medical condition and disability.

An accident means an unexpected "traumatic event or unusual strain identifiable by time and place of occurrence caused by a specific event during a single work shift." The prevailing factor is defined as the primary factor in relation to any other factor, causing both the resulting medical condition and disability.

An occupational disease is compensable only if the occupational exposure was the prevailing factor in causing the resulting medical condition and disability. Aging or normal activities of day-to-day living cannot be considered when determining if the occupational disease is compensable.

The same standards apply to repetitive motion injury. Occupational disease is compensable if the injured worker can demonstrate the workplace caused the occupational disease. The prevailing factor is defined as the primary factor in relation to any other factor, causing both the resulting medical condition and disability.

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After August 28, 2005, all injuries and occupational disease must meet the new standard of work being "the prevailing factor" in causing the injury or disease.

The law states that an injury resulting directly or indirectly from idiopathic causes is not compensable. An idiopathic injury is one that is innate or is a peculiar weakness personal to the employee, unrelated to employment.

Certain injuries that occur when the employee is going to and from the employer's premises are excluded. Under the law, only injuries that occur on property owned or controlled by the employer would probably be compensable.

An injury occurring in a company owned vehicle that is being driven by the employee to and from home would no longer be compensable. This provision would not affect injuries occurring while driving a company owned car while the person is performing his or her job duties.

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The law states that, with respect to any accident, an employee has to provide written notice of the time, place and nature of the injury, and the name and address of the person injured to the employer, no later than thirty days after the accident, unless the employer was not prejudiced by failure to receive the notice.

There is also a notice requirement for occupational disease or repetitive trauma injuries. The employee has to provide written notice of the time, place and nature of the injury, and the name and address of the person injured to the employer, no later than thirty days after the diagnosis of the condition, unless the employee can prove that the employer was not prejudiced by failure to receive the notice.

The employee can still file a Claim for Compensation with the Division within the applicable statutory period of limitations. The Administrative Law Judge, Commission or the Court of Appeals would determine the issue on whether the employee provided the notice to the employer or whether the employer was prejudiced by failure to receive the notice, as required by law.

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Under the law, if the employee fails to obey any rule or policy adopted by the employer on a drug-free workplace or on the use of alcohol or non-prescribed controlled drugs in the workplace, and the employee sustains an injury while using alcohol or non-prescribed controlled drugs, the compensation and death benefits shall be reduced fifty percent. If the employee's use of alcohol or non-prescribed controlled drugs in violation of the employer's rule or policy is the proximate cause of the employee's injury, the benefits or compensation payable for death or disability are forfeited.

Under the law there is a rebuttable presumption that the alcohol was the proximate cause of the injury if the voluntary use of alcohol to the percentage of blood alcohol in the employee's system meets the legal intoxication standard under Missouri law. An employee, by a preponderance of the evidence standard, can overcome the presumption that the intoxication was not the proximate cause of the injury.

Under the law, an employer can request an employee to take a test for alcohol or a non-prescribed controlled substance if the employer suspects usage by the employee or if the employer's policy clearly authorizes the post-injury testing. If the employer does request a test of the employee when an injury occurs and the employee refuses to take the test, the employee forfeits all workers' compensation benefits.

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The penalties for certain types of fraud are a class D felony. For example, any person who knowingly presents a false or fraudulent claim for the payment of benefits on a workers' compensation claim, or any insurance company or self-insured employer refusing to comply with known and legally indisputable compensation obligations with intent to defraud.

The following fraud cases are still regarded as a class A misdemeanor. These include, but are not limited to, to knowingly present multiple claims for the same occurrence with intent to defraud, to knowingly assist or conspire with any person who knowingly presents a false or fraudulent claim for the payment of benefits, to knowingly submit a claim for a health care benefit that was not used by or on behalf of the claimant, to knowingly make false or fraudulent statements with regard to entitlement to benefits with the intent to discourage an injured worker from making a legitimate claim.

If a person has previously been found to be guilty or pled guilty to workers' compensation fraud, and subsequently commits fraud, that person shall be guilty of a class C felony.

If a person prepares or provides an invalid certificate of insurance as proof of workers' compensation coverage the person is guilty of a class D felony and is liable to the state of Missouri for a fine up to ten thousand dollars or double the value of fraud, whichever is greater.

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Every employer who is subject to the requirements of the workers' compensation law must insure its entire workers' compensation liability with an insurance carrier that is authorized to insure such liability in the State of Missouri by the Missouri Department of Insurance or qualify to be a self-insured employer by the Division of Workers' Compensation. Noncompliance is the failure of the employer to carry workers' compensation insurance when required to do so under the law.

An employer who knowingly fails to insure its workers' compensation liabilities is guilty of a class A misdemeanor and liable to the state of Missouri for a penalty of up to three times the annual premium or up to fifty thousand dollars, whichever amount is greater. A subsequent violation is a class D felony.

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