Workers’ compensation provides injured workers several different benefits. Wage compensation during disability is a particularly important benefit. Wage loss compensation in workers’ compensation is called Temporary Total Disability Benefits. This article will explain why and how an injured worker is entitled to this benefit, how it is calculated, how long it continues and when it can be stopped. The Law on Disability Benefits
The law concerning temporary total disability benefits is 21 V.S.A. § 642. It states:
“Where the injury causes total disability for work, during such disability, but not including the first three days, the day of the accident to be counted as the first day, unless the employee received full wages for that day, the employer shall pay the injured employee a weekly compensation equal to two-thirds of the employee’s average weekly wage…”
The law also addresses specific details concerning the amount and duration of compensation. The first three days of disability are not compensated unless the injured worker is disabled 10 days or more. Also, while the injured employee generally receives two-thirds of their “average weekly wage,” the worker cannot receive less than the minimum or their weekly net income, nor more than the maximum. In addition, workers with dependent children receive an additional $10.00 per week per dependent child.
Injured Worker Needs To Present Proof of Disability
The injured worker has the burden of presenting proof for any benefit requested in the workers’ compensation system. In order to receive Temporary Total Disability Benefits, the injured worker must first present medical evidence from a physician indicating that the worker is disabled due to their work injury. Physicians write medical notes for each office visit. Such medical notes are often useful as proof of disability. The medical record or note should indicate that the worker is disabled due to their work injury. The injured worker should provide the note, or a copy of the note to his/her employer and to the insurance adjuster handling the workers’ claim. Failure to provide medical evidence of disability can result in delay or denial of disability benefits.
Benefit is Based Upon Worker’s Average Weekly Wage
As indicated previously, workers usually receive a benefit amount of approximately two-thirds of their average weekly wage. The “Average Weekly Wage” is based upon the worker’s actual wages over the 12 weeks prior to their date of injury. Shortly after the filing of a claim, the employer is asked to provide an accurate listing of the workers’ wages. The worker’s benefit rate is roughly two-thirds of the average derived from their 12 weeks of prior wages. The laws and rules provide guidelines for determining wages when the worker has been employed less than 12 weeks. There are also guidelines for workers who receive other benefits in lieu of wages.
Accuracy of the Worker’s Compensation Rate
The Vermont workers’ compensation division works to ensure that wages and benefits are computed accurately. Wage form filings by the employer/carrier are mandatory. Division staff review the wage filings and information. In addition, both the injured worker and the insurance adjuster must review and sign a Compensation Agreement (Form 21 – Agreement for Temporary Total Disability Compensation) which lists the worker’s average weekly wage, weekly compensation rate and other information specific to that worker.
Disputes Concerning Wage or Benefit Computation
Disputes over a worker’s wages or benefit rate are infrequent. Workers’ Compensation Rules take into consideration a variety of employment situations. Bonuses, concurrent employment, overtime, housing benefit and a wide range of other benefit and employment issues are considered by the Rules. In the event the parties maintain a dispute over wages, the workers’ compensation division will review evidence or documentation relevant to the dispute and attempt to resolve the disagreement based upon the Rules.
Workers’ compensation also provides a “partial disability” benefit. These benefits are provided when the injured worker is physically unable, due to their work injury to:
1. Work their full or usual work hours.
(Example – worker usually works an 8 hour day, medically released to work a 6 hour day)
2. Work at their usual job, thus earning lower wages while working at other suitable work.
(Example – worker usually earns $12/hour working as a machinist but due to injury cannot work at usual job but does perform work for employer at other suitable job earning $10/hour)
In the event a work is partially disabled, they are entitled to a benefit representing two-thirds of the difference between their pre-injury average weekly wage and their current earnings.
Stopping Temporary Total Disability Benefits
Disability benefits may be stopped by the insurance carrier for any of the following reasons:
1. Worker successfully returns to work;
2. Medical evidence supports that worker is at Medical End Result.
3. Worker has been medically released to return to work but fails to accept an offer of suitable work or fails to make a good faith effort to look for suitable work.
4. Lack of medical documentation supporting ongoing disability.
5. Worker fails to cooperate in his/her workers’ compensation claim.
Note: Disability benefits may be stopped despite continuing disability.
The two most frequent reasons for stopping disability benefits are successful return to work or Medical End Result. If the worker successfully returns to work the insurance company does not have to file a notice that it is stopping payment of disability benefits. If benefits stop for any other reason, then the insurance carrier must file a Notice of Intention to Discontinue Payments (Form 27), along with supporting evidence.
Medical End Result – Stops Disability Benefits
Disability benefits are provided during a worker’s period of disability, but only until the worker’s recovery period has ended. Workers’ compensation law provides that disability benefits may be stopped when the work injury is at “Medical End Result” 9also known as maximum medical improvement or end medical result). This means that the worker has reached a substantial plateau in their recovery process such that significant further improvement is not expected, regardless of treatment. Injured workers are sometimes surprised to learn that although they may continue to have disability or pain, and may require continuing medical treatment, if their condition has improved as much as it is going to, then their disability benefits may be stopped.
Medical End Result Does Not Stop Medical Benefits
A medical provider’s determination of Medical End Result may stop only disability benefits. This same finding is not sufficient to stop medical benefits. Medical benefits should be covered as long as they are reasonable and necessary and related to the work injury.
Disputes Concerning Entitlement to Disability
Disputes may arise over when or whether an injured worker is entitled to disability benefits and when such benefits may stop. As indicated previously, the injured worker has the burden of presenting medical evidence of their disability. However, once disability payments commence, the insurance carrier has the burden of presenting evidence in order to stop benefits. Medical records and information are the primary means of resolving these disputes. If an injured worker feels that s/he is entitled to disability benefits that have been denied or entitled to continuation of benefits after they have stopped, they should obtain and present new or additional medical evidence that supports their position. With any dispute in the workers’ compensation system, the worker should write a letter indicating what benefit they are seeking and should attach the evidence that supports their position.
The workers’ compensation address is :
Department of Labor
5 Green Mountain Drive
PO Box 488
Montpelier, VT 05601-0488
Phone: (802) 828-2286