What to Expect in a Workers’ Compensation Claim

Eventually, most job injury victims can expect a settlement. About 90 percent of workers’ compensation claims settle out of court. However, as outlined below, settlement is a process, not a result.

Workers’ comp is no-fault insurance that pays benefits to victims with job-related illnesses or injuries. So, although insurance companies cannot contest liability (legal responsibility), at least in most cases, they can and do bitterly contest damages (amount of benefits).

Workers’ compensation benefits include lost wage replacement and medical bill payment. Lost wages are based on the AWW (average weekly wage), a figure many insurance company lawyers intentionally miscalculate. As for medical bills, workers’ comp rules require insurance companies to pay “reasonably necessary” expenses, a phrase many adjusters translate as “cheapest possible.”

Only a Newark workers’ compensation lawyer builds a strong case and advocates for job injury victims, so they get the largest possible settlement.

Covered Claims

Workers’ comp usually applies to occupational diseases, like hearing loss, and trauma injuries, like motor vehicle crashes.

Hearing loss may be the most common occupational disease (an illness that develops over the course of more than one work shift). Full benefits are available even if a non-work or pre-existing condition contributed to the risk and/or severity of hearing loss.

Car crashes kill or seriously injure millions of Americans every year. Many of these wrecks are work-related. They injure or kill delivery drivers or people walking back to the office from lunch. In civil court, an attorney must normally prove negligence, or a lack of care, to obtain compensation in these cases. But as mentioned, a Somerset County workers’ compensation lawyer must only prove the vehicle collision was work related.

Incidentally, New Jersey law broadly defines “work related.” Employer benefit is the key concept. So, an injury at a company softball game is usually work related. The employer benefits because the company’s name is on the softball jersey and because happy and healthy employees are usually productive and cheaper employees (fewer sick days, lower insurance premiums, etc.).

Determining Legal Options

Usually, workers’ compensation is the exclusive remedy for work-related illnesses and injuries. This rule, like most others, has some exceptions. So, before a Union County personal injury lawyer barks up the wrong tree, an attorney must analyze all possible legal options. A civil action is an option if:

• Uninsured Employer: Obviously, workers’ comp benefits are only available if the employer has a valid policy. Some employers ignore the law and don’t buy policies. Others lie to their carriers, mostly about payroll size, and carriers cancel the policies.
• Defective Product: Manufacturers are normally strictly liable for any injuries their defective products cause. These companies cannot hide behind workers’ compensation laws to avoid facing the music.
• Reckless/Intentional Illness/Injury: Workers’ comp only applies to unintentional injuries. It doesn’t apply to reckless or intentional ones. Employers are usually reckless if they knowingly send workers to dangerous areas. Injuries are intentional if the employer has an ax to grind with the employee.

Victims must file civil claims if the employer was uninsured. They have no other means of compensation. Since these companies broke the law, they cannot use some key defenses, such as assumption of the risk. So, it’s easier to prove negligence, or a lack of care.

Roughly the same environment applies in defective product cases. A few limited defenses, such as extreme product misuse, are available. Extreme product misuse is a situation like using a lawnmower to trim ivy on a brick wall.

Reckless/intentional injuries are a high risk and high reward proposition. All defenses are available, so negligence is hard to prove. The reward is additional compensation, such as money for noneconomic damages, as well as additional punitive damages.

Initial Review

Before we discuss the initial review, we should discuss some important background information, namely the declining workers’ compensation premium rates in New Jersey. Regulators reduced rates by 7 percent for 2025. This reduction came after three consecutive years of similar reductions.

As a result, workers’ compensation bureaucrats are very stingy. Quite simply, there’s not enough money in the system to compensate all injured workers.

This stinginess greatly affects Claims Examiner reviews. These reviews are usually based on medical records and nothing more. Claims Examiners typically use actuarial tables to determine compensation. For example, a victim with X injury in Y Zip code receives Z compensation. Claims Examiners almost never examine the circumstances of the injury.

Because of the limited money and limited review, the Claims Examiner denial rate is extremely high. At this point, many victims either abandon their claims or settle them for pennies on the dollar. So at this point, an Atlantic County personal injury lawyer is often more of a cheerleader than an advocate.

Collecting Evidence

Medical records are only part of the evidence in a workers’ compensation claim. An attorney needs additional evidence to obtain maximum benefits.

Medical records are often incomplete or inaccurate. That’s especially true in states like New Jersey, where job injury or illness victims must see company doctors, at least in most cases. To male up for these deficiencies, a Bergen County personal injury lawyer often obtains an independent medical examination from an independent doctor.

This review usually includes evaluating existing medical records and determining their accuracy, as well as a patient examination. These professionals usually have much more credibility than company doctors. Additionally, independent doctors are pros on the witness stand.

Lay testimony often supplements medical evidence. For example, AMy’s husband probably cannot testify about the workplace accident that caused her injury. However, he can testify about how that injury affects her daily life. In other words, lay testimony personalizes medical testimony.

Electronic evidence, such as surveillance camera footage, is often essential as well. The old saying is true in many cases. Frequently, a picture is worth a thousand words. That’s especially true if a tech-savvy Essex County personal injury lawyer shows HD video footage on a large screen.

ALJ Appeal

After a lawyer develops a workers’ compensation case, coinsurance company lawyers are usually willing to make favorable deals. The stronger case intimidates many insurance company lawyers. Furthermore, these lawyers know what’s coming next.

An Administrative Law Judge appeal is nothing like a Claims Examiner review. Instead of a paper review, an ALJ hearing is basically a trial. Attorneys can introduce evidence, challenge evidence, and make legal arguments.

Many times, ALJs are either insurance company employees or affiliated with insurance companies in some way. However, ALJs are almost always fair. Usually, a Hudson County personal injury lawyer only needs a fair chance to obtain maximum benefits.

Contact a Savvy Morris County Lawyer

Injury victims are entitled to significant compensation. For a free consultation with an experienced personal injury lawyer in Newark, contact CourtLaw. We do not charge upfront legal fees in these matters.