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Workers' Compensation Glossary of Terms

This glossary defines commonly used terms related to workers’ compensation. These definitions are not intended to constitute (and should not be used or interpreted as) legal definitions. Terms and definitions may vary by state.

 
A - C      D - L      M - P      Q - T      U - Z

- A -

Accepted condition: A medical condition for which an insurer accepts responsibility for the payment of benefits on a claim filed by an injured worker (also called accepted claim).

Accident: An event, arising out of and in the course of employment, that results in personal injury to a worker.

Administrative law judge: An employee of the Workers' Compensation Board who makes decisions about workers’ compensation disputes and approves settlements (also called workers’ compensation judge). May also review appealed administrative orders, hold impartial hearings, and issue legal opinions.

Aggravation claim: A claim for further benefits because of a worsening of the claimant's accepted medical condition after the claim has been closed.

Alternative dispute resolution (ADR): A voluntary process through which parties resolve disputes instead of using the formal hearing process.

Americans with Disabilities Act (ADA): A federal law that prohibits discrimination against people with disabilities and directs employers to make reasonable accommodations for people with disabilities.

Ancillary care: Care such as physical or occupational therapy provided by a health care provider other than the attending physician, specialist physician, or authorized nurse practitioner.

Appeal: A legal action taken by one of the parties to reverse or amend a decision or direction in regards to a workers' compensation claim.

Apportionment: A proportionate division of all or part of the liability in a case between two or more sources of disability for the same claimant, based on an evaluation of the relative contribution that the sources of disability have made to the claimant's permanent disability.

Arising out of and in the course of employment (AOE/COE): Two necessary conditions that must be met to establish a work-connected accidental injury; an injury that "arises out of" is one that results from a hazard of the employment, while an injury "in the course of employment" is one that occurred at a time, place and under circumstances related to the employment.

Attending physician: A health care provider primarily responsible for the treatment of an injured worker (also called primary treating physician or treating physician).

Average weekly wage (AWW): Average weekly wage of workers in covered employment which may be used to calculate benefit rates for temporary disability, permanent partial disability, permanent total disability, and death.

- B -

Beneficiary: An injured worker's spouse, domestic partner, child, or dependent entitled to receive payments under workers' compensation law.

- C -

Claim: A written request by the worker, or on the worker's behalf, for compensation.

Claim form: The form used to report a work injury or illness to the employer.

Claimant: A person who files a claim for occupational disease or injury benefits under workers' compensation law.

Claims administrator: The term for insurance companies or insurer representatives who process workers’ compensation claims filed by workers (also called claims examiner or claims adjuster).

Combined condition: Occurs when a pre-existing condition combines with a compensable condition. A combined condition may cause disability or prolong treatment.

Commutation: An order by a workers' compensation judge for a lump sum payment of part or all of a permanent disability award.

Compensable injury: An accidental injury to a person or prosthetic appliance, arising out of and in the course of employment that requires medical services or results in disability or death. A claim is compensable when it is accepted.

Compromise and release (C&R): A settlement agreement between the parties to a workers’ compensation claim that resolves all or some of the issues in the case (also called claim disposition agreement or CDA).

Consequential condition: A condition arising after a compensable injury and for which the major contributing cause is the injury or treatment rendered that increases either disability or need for treatment.

Consulting physician: A physician who advises the attending physician or authorized nurse practitioner regarding the treatment of a worker's injury.

Contested-case hearing: A formal proceeding at which parties can present evidence in support of their case to an administrative law judge who issues an order resolving the dispute.

Cumulative injury: An injury caused by repeated events or repeated exposures at work.

- D -

Date of injury: When the worker got hurt or ill. If the injury was caused by one event, the date it happened is the date of injury. If the injury or illness was caused by repeated exposures (a cumulative injury), the date of injury is the date the worker knew or should have known the injury was caused by work.

De facto denial: The failure of an insurer to accept or deny a claim within the statutory time frame.

Death benefits: Benefits paid to surviving dependents when a work injury or illness results in death.

Deferred claim: A claim not yet accepted or denied by the insurance company or self-insured employer.

Denied claim (denial): A written refusal by an insurer to accept compensability or responsibility for a worker's claim of injury.

Disability: A physical or mental impairment that limits an individual’s life activities. A condition that makes engaging in physical, social and work activities difficult.

Disability management: A process to prevent disability from occurring or to intervene early, following the start of a disability, to encourage and support continued employment. May involve a rehabilitation nurse along with the treating physician. The progress of medical treatment is typically reported to the insurance company.

Disability payment: The payment for disability resulting from an accident or disease from which a worker is not expected to recover. May be partial or total.

Disabling claim: An injury which causes the worker temporary disability, permanent disability, or death. A claim may also be classified as disabling if there is a reasonable expectation that permanent disability will result from the injury.

Disabling compensable injury: An on-the-job injury that entitles the worker to temporary, permanent partial, or total disability payments, or results in death benefits.

Dispute: A disagreement about the right to payments, services or other benefits.

- E -

Employee: A person whose work activities are under the control of an individual or entity.

Employer: Any person or entity that contracts to pay for work or services, with the right to direct and control the work or services of any person.

Employer-at-injury: A worker's employer at the time the worker was injured.

Ergonomics: The study of how to improve the fit between the physical demands of the workplace and the employees who perform the work. That means considering the variability in human capabilities when selecting, designing or modifying equipment, tools, work tasks and the work environment.

Essential functions: The primary job functions or tasks that an individual must be able to perform with or without a reasonable accommodation.

Ex parte communication: Generally a private communication with a judge regarding a disputed matter without the other party being present or copied with correspondence.

Exclusive remedy: Basic concept that an employee injured on the job is entitled to workers' compensation benefits but may not sue the employer for damages. Workers' compensation is thus the exclusive remedy for a work-related injury.

- F -

Family and Medical Leave Act (FMLA): A federal law that provides certain employees with serious health problems or who need to care for a child or other family member with up to 12 weeks of unpaid, job-protected leave per year. It also requires that group health benefits be maintained during the leave.

Federal employer identification number (FEIN): A number assigned to a business by the Internal Revenue Service.

Filing: Sending or delivering a document to an employer or a government agency as part of a legal process. 
 
Final order: An order, decision or award made by a workers' compensation judge that has not been appealed in a timely way.
 
Findings & award (F&A): A written decision by a workers' compensation administrative law judge about a case, including payments and future care that must be provided to the worker. The F&A generally becomes a final order unless appealed.

Fraud: Any knowingly false or fraudulent statement for the purpose of obtaining or denying workers' compensation benefits. Each state has certain penalties for committing fraud including fines and/or imprisonment.
 
Future medical: On-going right to medical treatment for a work-related injury.

- H -

Health care provider: A person duly licensed to practice one or more of the healing arts (also called medical service provider).

Hearing: A formal proceeding at which parties can present evidence in support of their case to an administrative law judge who issues an order resolving the dispute.

HIPAA (Health Insurance Portability and Accountability Act): A federal law that ensures the privacy and security of protected health information and patients' access to their health-care records.

- I -

Impairment findings: A permanent loss of use or function of a body part or system as measured by a physician.

In pro per: An injured worker not represented by an attorney. 

Independent contractor: A person contracted to do work who is not subject to the direction and control of an employer. Unless independent contractors purchase workers' compensation insurance coverage for themselves, they generally cannot collect benefits for on-the-job injuries or illnesses. Labor law enforcement agencies and the courts look at several factors when deciding if someone is an employee or independent contractor.

Independent medical examination (IME): A medical examination of an injured worker by a physician other than the worker's attending physician performed at the request of the insurer. This includes physical capacity evaluations and work capacity evaluations, if requested by the  insurer. The insurer or self-insured employer pays for this examination.

Insured employer: An employer who has workers' compensation insurance to cover work injuries of subject workers.

- J -

Job analysis: A detailed report outlining the specific job duties of a worker related to the physical requirements of the job.

- L -

Lien: A right or claim for payment against a workers' compensation case. A lien claimant, such as a medical provider, may follow specified procedure to request payment of money owed in a workers' compensation case.

Litigation: A legal process that usually results in a judge deciding the resolution of the dispute based on the facts and the law.

Lump sum: The payment of a permanent disability award in one check.

- M -

Major contributing cause (MCC): A cause deemed to have contributed more than 50 percent to an injured worker's disability or need for treatment.

Managed care organization (MCO): An organization that contracts with an insurer to provide medical services to injured workers.

Mandatory settlement conference (MSC): A required conference to discuss settlement prior to a trial.

Maximum Medical Improvement (MMI): An assessed condition of a claimant based on medical judgment that the claimant has recovered from the work injury to the greatest extent that is expected and no further change in his/her condition is expected, with or without medical treatment. A finding of maximum medical improvement is a normal precondition for determining the permanent disability level of a claimant (also called medically stationary).

Mediation: The act of facilitating agreement and settling differences between disputing parties.

Medical provider: A health care provider, hospital, medical clinic, or vendor of medical services.

Medical-legal report: A report written by a doctor that describes the worker’s medical condition. These reports are written to help clarify disputed medical issues.

Medical treatment: Treatment reasonably required to cure or relieve the effects of a work-related injury or illness (also called medical care).

Modified work: A modification to an injured worker's job duties or work schedule to accommodate the physical limitations resulting from the injury or disease.

- N -

National provider identifier (NPI): A unique identification number assigned to health care providers, individuals, groups, or organizations that provide medical or other health services or supplies.

Nondisabling claim: A worker's compensation claim that does not result in time-loss or permanent disability, but requires only medical treatment (also called medical only).

Notice of Acceptance (NOA): A notice from the insurer or self-insured employer that informs the worker that the worker's claim has been accepted.

Notice of Compliance: A notice that must be posted in the employer's place of business, which shows the employer has complied with workers' compensation insurance coverage requirements.

 - O -

Objective findings: The indications of injury or disease that are measurable, observable, and reproducible, used to establish compensability and determine permanent impairment (also called objective factors).

Occupational disease: A disease or infection, arising out of and occurring in the course and scope of employment which is caused by substances or activities to which an employee is not ordinarily subjected or exposed other than during employment and requires medical services or results in disability or death.

Occupational Safety and Health Administration (OSHA): The federal agency that oversees workplace safety and health in federal offices and in states without state OSHA programs.

Offset: A reduction of compensation to a worker to recover an overpayment or because the worker is receiving federal social security disability benefits.

Opinion and order: A formal decision issued by an administrative law judge at the Workers' Compensation Board that resolves a dispute.

Overpayments: Money paid to an injured worker by the insurer that is more than is due the worker.

- P -

Palliative care: Medical services rendered to reduce or temporarily moderate the intensity of an otherwise stable condition to enable the worker to continue employment or training.

Partial denial: Denial by the insurer of one or more conditions of a worker's claim, leaving some conditions of the claim accepted as compensable.

Party: Normally includes the insurance company, employer, attorneys and any other person with an interest in the worker’s compensation claim (such as doctors or hospitals that have not been paid).

Penalties: An action taken against a party for violations of workers' compensation laws or rules, such as monetary fines or suspension of benefits.

Permanent disability (PD): Any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached.

Permanent disability benefits: Payments received when a work injury permanently limits the kinds of work an individual can do or the ability to earn a living.

Permanent disability payments: Mandatory payments based on the undisputed portion of permanent disability received before and/or after an award is issued.

Permanent impairment: The permanent loss of use or function of a body part or system due to a compensable injury.

Permanent partial disability (PPD): The permanent loss of use or function of any portion of the body.

Permanent partial disability benefits: Payments received when a work injury partially limits the kinds of work an individual can do or the ability to earn a living.

Permanent total disability (PTD): The loss of use or function of any portion of the body, in combination with any pre-existing disability that permanently prevents the worker from regularly performing gainful and suitable work.

Permanent total disability benefits: Payments received when an individual is considered permanently unable to earn a living.

Physical capacity evaluation (PCE): Measurements of a worker's ability to perform a variety of physical tasks.

Pre-existing condition: A medical condition that existed before the compensable injury or disease.

Premium: The amount of money an employer pays an insurance company for a workers' compensation policy.

Preponderance of evidence: Evidence that is of greater weight or more convincing than evidence on the other side of the issue. In workers' compensation, the term is often used in relation to weighing medical opinion.

Pro se: A party that participates in a formal or informal dispute process without an attorney.

Proof of service: A form used to show that documents have been sent to specific parties.

Prosthetic appliance: The artificial substitution for a missing body part, such as a limb or eye, or any device that augments or aids the performance of a natural function, such as a hearing aid or glasses.

- R -

Reconsideration: A legal process to appeal a decision issued by a workers' compensation judge.

Regular work: The job the worker held at the time of injury or a substantially similar job.

- S -

Sanctions: An action taken against a party for violations of workers' compensation law or rules, such as monetary fines or suspension of benefits.

Security: Deposits, bonds, assignments, and certificates of title provided by self-insured employers to guarantee payment of compensation for injuries or other existing debts.

Self-insured employer: An employer that directly assumes financial and processing responsibility for workers' compensation benefits rather than purchasing an insurance policy.

Service company: A company contracted by a self-insured employer or insurer to administer its workers' compensation claims (also called a third-party administrator).

Settlement: An agreement between a worker and the insurance company about workers' compensation payments and future medical care.

Social Security disability benefits: Long-term financial assistance for totally disabled persons. These benefits come from the U.S. Social Security Administration and are generally reduced by workers' compensation payments the worker receives.

Social Security offset: A reduction of permanent total disability benefits based upon the amount of federal Social Security disability benefits received by a worker.

Specific injury: An injury caused by one event at work.

Stipulation: An agreement reached between an insurer and worker.

Subjective factors: The amount of pain and other symptoms described by an injured worker that a doctor reports as contributing to a worker's permanent disability.

Subpoena: A document that requires a witness to appear at a hearing.

Subpoena Duces Tecum (SDT): A document that requires records be sent to the requester.

Superimposed condition: A condition arising after and not related to the compensable injury that increases disability or need for treatment.

Supplemental disability: Additional wage loss replacement due a worker employed in more than one job at the time of injury.

Suspension of benefits: An interruption of payment of benefits to an injured worker.

- T -

Temporary disability (TD or TTD): Payment for loss of wages because an injury prevents the worker from doing his or her usual job while recovering.

Temporary partial disability benefits (TPD): Payment for wages lost when a worker is only able to perform modified or part-time work because of a compensable injury.

Temporary total disability benefits (TTD): Payment for wages lost when a worker is unable to work because of a compensable injury.

- U -

Unrelated condition: A medical or physiological problem not medically related to the injury.

- V -

Vocational rehabilitation counselor: A certified vocational counselor hired by the insurer to provide vocational assistance to the injured worker.

Vocational Rehabilitation Organization (VRO): A business that provides, at an insurer's request, vocational assistance to injured workers.

- W -

Work capacity evaluation (WCE): A physical-capacity evaluation that focuses on the ability to perform work-related tasks.

Work restrictions: A doctor's description of the work an individual can and cannot do.

Worker: Any person who provides services for pay under the direction and control of an employer.

Workers' Compensation Board (WCB): Generally the state organization responsible for conducting hearings and reviewing legal decisions and agreements that affect injured workers' benefits.

Worksite modification: The changes made to an injured worker's job, tools, tasks, or worksite to accommodate the worker's injury-caused limitations.


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