Is There DEDUCTIBLE or CO-PAY in Workers Compensation?

From the roadside view, the roofers are seen doing their installation on the negatively sloped roofs on the houses.

Under the Virginia Workers Compensation Act, an injured worker does not have to pay a deductible for their treatment. Medical bills are to be paid, 100% with no co-pay under the AWARD. The injured worker should not be “out of pocket” for medical bills that are reasonable, related, and by referral. While the injured worker should not be liable for paying any co-pays and/or deductibles, in a Worker’s Compensation awarded case, their employer, insurance company, or third-party administrator will likely not be paying the full retail price. With the advent of the Virginia Workers Compensation Medical Fee Schedule, the amount that doctors, hospitals, and therapists are allowed to charge is now easily ascertained online. The doctors in a Virginia Worker’s Compensation claim are not allowed to “balance bill “the patient. In other words, if the doctor, Hospital, or radiology facility charges an injured worker $10,000 for treatment, MRIs, and x-rays, and, pursuant to the Virginia Medical Fee Schedule, the insurance company pays only $7,000, the health care providers are not allowed to “balance bill” the patient the unpaid $3,000 difference.

When an employer has Worker’s Compensation insurance, the injured worker, and their lawyer are generally dealing with the insurance company and not the employer. The insurance company makes the decisions on whether or not to accept the claim and pay for the medical care, except disability from work, prescription, expenses, etc. It is usually the insurance company’s money from the first dollar, as they have accepted the premiums paid by the employer of the injured worker. However, there may be money that the employer has to pay before their insurance company even pays their first dollar.

These flat-topped roofs on the top of DC seem far less accident prone and more scenic.

Employers in high-risk occupations, such as roofers, blasters, construction, and demolition, will obtain a $500,000 self-retention insurance policy to save money. This means that the compensation benefits of up to half a million dollars are paid by the employer, while commercial insurance covers costs exceeding that amount.

Although there is no maximum payout for Worker’s Compensation claims, due to the absence of a cap on medical expenses, indemnity payments are usually limited to 500 weeks for most cases. This helps insurance companies determine their potential liabilities before entering into a contract.

Just as individuals may have high deductibles to save money on with their personal insurance, such as with cars, homeowners, and other coverages, it is not unusual for businesses in dangerous occupations to do the same.

“According to the Bureau of Labor Statistics (BLS), the total rate of injuries/illnesses for roofing contractors was around 7,100, or 36 per 1,000 full-time equivalent (FTE) workers in 2021.”

Compare that statistic to the dangers of being a paralegal in a law firm which are slim to none! Obviously, the premiums charged by the insurance company would be a lot higher for the roofing trade than the Law Office!

Many employers in Virginia, including city, state, and municipal governments, option for partial self-insurance and hire a third-party administrator (“TPA”) to handle claims, payments, and paperwork.

Does this save the money?

Herndon Injury Lawyer Doug Landau, says the TPAs can act like another “layer on the onion. ” They often contribute to a greater expense to the account. If looking to hire a TPA, it is important to evaluate a cost-benefit analysis. TPAs charge fees and companies that are smaller in size may not actually “reap the benefits.”

If you, or someone you know, has been injured on the job and has questions about their claims, co-pays, deductibles, insurance coverage, or other legal rights, please contact us at 703–796–9055 or email