Workers' compensation claims
As an employer, your primary responsibility is providing a safe workplace. But if one of your employees is injured on the job, you’re also responsible for making sure a workers’ compensation claim is filed. Each state has its own workers’ compensation regulations, so the claims process varies depending on where your business is located.
When can an employee file a workers’ comp claim?
An employee can file a workers’ compensation claim for injuries that occur on the job or within the scope of employment. This includes occupational accidents, diseases, trauma injuries, or illness caused by exposure to work activities or chemicals.
Workers’ comp generally doesn’t cover:
- Stress or other psychiatric injuries.
- Self-inflicted injuries.
- Injuries caused by fighting or horseplay.
- Injuries that happen on the commute to or from work.
- Injuries incurred while committing a crime, while under the influence of drugs or alcohol, or while violating company policies.
The following must be true to file a claim:
- The injured worker is an employee of your business (not an independent contractor).
- The employer has workers’ compensation insurance.
- The employee was injured or became ill as a result of job-related duties.
What’s the procedure for filing a workers’ comp claim?
The worker has a limited amount of time to submit paperwork and receive benefits, so act promptly when an injury occurs. It’s important to comply with regulations – otherwise the claim could be denied.
When an injury occurs, the employer must:
- Give the employee the appropriate paperwork and guidance.
- File the claim with the insurer.
- Comply with state law for reporting work injuries.
The employee must:
- Notify the employer of the injury (date, time, type of injury, and how the injury occurred).
- File a formal workers’ comp claim.
For very small businesses, the business owner is often responsible for filing the claim.
Steps for filing a workers’ comp claim
- The employee reports an injury to the employer.
To make a workers' comp claim, the employee's injury or illness must be work-related. This could include slipping on an ice patch on business property or developing asthma from exposure to fine particulate in the workplace.
In emergency situations, the employee should be rushed to the emergency room. For less immediate concerns, the employee should consult a doctor for a diagnosis and medical report to file with the claim.
In some states and with some insurers, the employee needs to visit a medical provider that’s part of the insurer’s network to receive benefits.
With injuries or illnesses that surface over time, such as mesothelioma (caused by exposure to asbestos), the employee needs to report to you as soon as the injury or illness is recognized.
In most states, the employee must report the injury or illness to the employer within a certain number of days after it occurs. In Colorado, the employee must provide written notice within four days of the injury. In Iowa, the deadline is 90 days.
- The employer provides paperwork.
Once you're notified about the injury, give the employee:
- The proper reporting forms for your insurance provider, including a claims form.
- A form for reporting to the state workers’ comp board (depending on where you live).
- Access to an approved medical practitioner. Except in the event of an emergency, a medical professional approved by your state's workers' compensation board must treat all workplace injuries and illnesses.
- Information on the employee’s rights and workers’ comp benefits.
- Information about returning to work.
- Compensation for minor injuries. Employers may choose to pay for treatment of a minor injury (as defined by state regulations) out of pocket to avoid filing a claim with the insurance company.
The forms you need depend on your state, the type of illness or injury, and your insurer. If possible, give this information to your employees before they seek treatment. In fact, it’s a good idea to include your workers' comp insurance information in your employment packet for new hires. Failure to give your injured employees this information could lead to lawsuits.
As with the accident report, each state has its own laws for how much time can pass after an injury for a workers’ comp claim to be filed.
- The employer files the claim.
Usually, you're responsible for submitting the paperwork to your insurance carrier, but the employee’s doctor needs to mail the medical report. There may be a time constraint for submitting these forms, so don't delay. The insurance company generally provides the correct forms, but you may need to acquire them independently.
Additionally, you may need to submit documentation to your state’s workers' compensation board or other similar entity. This may apply for all workplace injuries, even if the employee is not seeking workers’ comp benefits.
If the employee needs to file a separate notice with the state board, inform the employee of that obligation.
- The insurer approves or denies the claim.
Once the claim is filed, the insurer will either approve the claim and contact the employee for payment details or deny the claim if it doesn’t qualify for workers’ compensation. The insurance company may choose a doctor to conduct an independent medical examination (IME), which is used to create an appropriate compensation offer.
If the insurer approves the claim, the employee may:
- Accept the payment offer, which may cover costs for medical bills, medicine, disability payments, and a portion of lost wages.
- Negotiate for a lump-sum settlement or larger structured settlement.
If the insurer denies the claim:
- You can ask the insurer to review the decision if you believe the decision is wrong.
- The employee can appeal the decision.
Either way, the rest of the process is between the employee, the employee’s legal representation (if any) and doctors, and the insurance company. In both instances, the insurance provider will notify the workers’ comp board of its decision.
- The employee returns to work.
When the employee recovers and wants to return to work, the employee must alert you and the insurance company via a written notice. Depending on the severity of the injury, the insurance company may continue paying disability benefits.
If employees at your workplace continue to experience occupational injuries, your workers’ comp premium may increase. Make sure you provide safety training, and hire workers with the skills to do their jobs safely.
What happens if the claims process is not followed correctly?
It’s crucial that employers follow the correct claims procedure and supply employees with the proper information so that they can do the same. Employers can be fined for:
- Not carrying workers’ compensation insurance.
- Not supplying employees with accurate information.
- Failing to report injuries or file claims on time.
- Misclassifying employees or injuries.
- Influencing a medical practitioner’s diagnosis.
- Appealing a claim without probable cause.
If you have employees and your state requires you to provide workers’ comp benefits, don’t delay on getting insured. Apply for quotes from Insureon today. Most small businesses can get workers’ comp coverage in 24 hours, depending on their state.