Getting injured on the job can be scary for all involved. At least with workers’ compensation insurance, employees and employers know that the cost of care will be covered and that employees will get disability payments to offset their lost wages. But to make sure employees get all benefits, it’s important to know the workers’ comp claims process.
While the steps for filing a claim vary from state to state and carrier to carrier, there are some basic guidelines to keep in mind. Knowing your state’s process helps ensure benefits are paid in accordance with regulations.
How to File a Workers’ Comp Claim
Making sure all the paperwork is completed and submitted based on the state-regulated deadlines ensures that injured or ill employees get the workers’ comp benefits they need quickly and with minimal problems.
1. Employee Gets Medical Attention
The first step in any workers’ compensation claim is getting the employee the necessary emergency medical care needed to care for any injury. Getting the right medical attention may require first aid, an ambulance, going to the emergency room, or seeing a primary care doctor. It’s important that employers make sure the employee gets immediate medical care to prevent further injury and address existing injuries.
Note that states can have very different rules surrounding initial medical treatments. For example, South Carolina employers have the right to choose the doctor that workers’ compensation pays for. This can impact the employee’s benefits if an employee wants to see a specific medical care provider. Other states like California mandate that the first $10,000 in medical benefits be paid out immediately to ensure there is care even before a claim has been approved.
It’s up to the employer to know what’s required when they’re first made aware of an injury. Employers should be clear what their rights, and their employees’ rights are when getting medical attention for injured workers and always make sure that proper medical attention is provided to anyone injured on the job.
2. Employee Notifies Employer
It is important that employees notify their employers of any workplace injury or illness. Most states require this happens as soon as possible, but some set a time frame for when notification has to be given or employees risk losing benefits. That may mean employees need to report incidents where injuries appear minor and there is no need for immediate medical attention. Employees should still document these incidents in case a minor injury worsens.
For example, say an employee slips and falls but doesn’t realize he’s injured his back until the next day. If he notified his employer the day of the accident, then he can be sure that he’s fulfilled the notification requirement. Not every incident will result in a workers’ compensation claim, but every incident should be documented in the event that there is a later problem that arises.
Pro tip: One of the most important best practices for managing workers’ comp claims for employers is to get the details of any workplace incident in writing. They can do this by creating a standard form for employees to complete. The incident report should include the day and time of the accident, what happened, the type of injury (or possible injury), and note any witnesses to the incident.
3. Employer Provides Paperwork
When an employer knows about an injury or illness and wants to file a claim, they usually need to get the employee the initial paperwork. In many states, this is called the First Report of Incident and often has to be filed within a certain period of time to be valid — typically around 30 days. However, no benefits can be paid until the form is completed, and the claim is processed.
Employers should note that, in some states, they are responsible for filing a first report of incident form with their workers’ compensation board. Depending on their state, they may also have to provide their employee with documents explaining the employee’s rights.
4. Employer Files Claim
Once the employer receives the First Report of Incident or other initial paperwork, they will file a claim with the insurance carrier and — in some states — notify the state workers’ compensation board. Just as the employee must file his paperwork within a designated period of time, so must the employer to avoid penalties and fines. The time frame varies by state. New York, for example, requires employers to file the claim within 10 days from the accident or the first report of the injury.
Employers must accommodate the injured employee. This means that they must provide time off without penalties if needed, and they must hold the employee’s position in anticipation that they will return to work. If the employee can work while injured, the employer must provide at-work accommodations so the employee can manage tasks even while hurt. The employer can only fill the position if the employee’s injury will prevent them from returning to their original job.
5. Insurer Approves or Denies Claims
The insurance carrier will take into account all the details of the incident. If necessary, they will launch an investigation into the details leading up to the incident to look for employer liability, employee liability, or fraud.
States vary on timelines, but there is a finite number of days that the insurance carrier has to review the claim and either approve it or deny it. This timeline can be anywhere from 14 to 30 days, contingent on state laws. Additionally, the state workers’ compensation board monitors claim decisions to look for areas where claims may be erroneously denied by companies or insurance carriers.
What Happens When a Claim Is Approved
If the claim is approved, the injured employee can receive all eligible benefits, such as:
- Medical care
- Physical therapy
- Lost income payments
- Vocational rehabilitation
In some cases, the insurer may offer the injured worker a settlement to close the case. The settlement may be for a lump sum or structured payments over time.
What Happens When a Claim Is Denied
Injured workers have the right to dispute or appeal claims when they’re denied. While it varies from state to state, injured employees must appeal the decision within a given time frame, often 30 days. If an employee feels that they were not provided the benefits owed to them, they may obtain legal representation to address the issues at hand.
6. Employee Returns to Work
Hopefully, the employee will be well enough to return to work. Once again, it is important that employers not fill the position with anyone other than temporary help unless they receive notice that their employee will not return to work. This may happen if a claim goes on for more than a year, and the employer can’t hold the position any longer.
In some cases, an employee may only be able to return to limited duties, often made possible with modifications to his:
- Job duties
- Work hours
If an employee cannot return to work, he will be eligible for permanent disability through the workers’ compensation policy. Where possible, employers can retrain employees for jobs that the employee can perform even with a permanent disability.
What Are the Employer’s Responsibilities in Workers’ Comp Claims Process?
Employers play an integral role in making sure that workers’ comp claims are processed properly and expediently. As such, there are certain employer’s responsibilities to be mindful of. Their role in the claims process starts with getting medical attention to the injured employee immediately. From there, filing paperwork on time is required by state laws. The employer should comply with all requests for information from the insurance carrier and the state workers’ compensation board.
The workers’ compensation claims process has many moving parts that involve the employee, the employer, medical providers, and insurance carriers. It’s important that everyone responds to details quickly to ensure the employee gets the care needed to get healthy and return to the job sooner than later.