Workers' compensation claim process for businesses

Whether an employee falls off a ladder and breaks their arm or develops mesothelioma after years of on-the-job asbestos exposure, it’s important to start the workers’ comp insurance claims process as soon as possible.

This process involves a few steps that must be taken to receive coverage for incident-related costs, including medical bills, disability benefits, and legal expenses in the event of a lawsuit.

Employers are responsible for submitting a workers’ comp claim within their state’s mandated timeframe. Workers’ compensation laws vary by state, so be sure to check your state’s rules and deadlines to ensure you comply—failure to do so could result in a denial of benefits.

The quicker you report an incident, the quicker your workers’ comp provider can initiate the claims process.

Most states, including New York and California, give employees 30 days to report incidents to their employer. However, reporting requirements vary by state, from three days in South Dakota to 90 days in Michigan.

When you contact your insurance company, have this information handy:

• Your policy number
• Details about exactly what happened
• Date, time, and location of the incident
• Contact information of anyone involved

Employers must also notify the Occupational Safety and Health Administration (OSHA), a division of the U.S. Department of Labor, in the event of:

• Fatalities: Within 8 hours of learning about a work-related death
• Severe injuries: Within 24 hours of any work-related inpatient hospitalization, amputation, or loss of an eye

It’s crucial to collect as much information about the incident as possible so that you can provide your insurer with a clear picture of what happened and why the employee needs benefits. This list should include:

• Employee’s full details, including name, phone number, Social Security number, hire date, and wages
• Employee’s completed form
• Date, time, and location of the incident
• A detailed description of the injury or illness
• Statements from any witnesses
• Potential work restrictions
• Any other documentation about the incident, including photos, emails, or text messages

Once you’ve filed your employee’s claim, the insurer will assign a claims adjuster to review the eligibility of the claim. This process might include:

• Reviewing the incident report: The adjuster will typically check the timeliness and details of the report and claim form, including how the injury or illness occurred.
• Examining medical records: The adjuster may review the employee’s medical treatment, diagnoses, and physicians’ reports for consistency and potential pre-existing conditions.
• Verifying background checks: The adjuster could review the claimant’s work, medical, and insurance history.
• Conducting employer or witness interviews: The adjuster may wish to gather additional information from the employee’s co-workers, manager, or other relevant parties.
• Opening a deeper investigation: If the adjuster has suspicions about the claim’s credibility, they may engage private investigators, monitor social media accounts, or speak with the employee’s family, friends, or neighbors.

Once the adjuster has reviewed all of the collected information, your insurer will either approve or deny your claim. After the claim is approved or denied, the insurer will inform the employer and contact the employee with details, from which point one of the following actions can be taken:

Once your employee has recovered and can return to work, they’re required to provide written notice to you and your insurance provider. Depending on the severity of the injury, the insurance company may have to pay permanent disability benefits.

To ensure a smooth return to work, many employers will establish a process through their workers’ compensation program that can help with:

• Modifying an injured worker’s duties
• Training employees on other skills if they can’t resume regular tasks
• Providing injured employees with accommodations so they can be comfortable and productive

An employee’s injury or illness likely qualifies for workers’ compensation benefits if it occurred on the job or within the scope of employment. This includes occupational illnesses or occupational diseases caused by exposure to harmful chemicals or other hazards while on the job.

To file a claim, all of the following must be true:

• You have an active workers’ compensation policy
• The injured worker is an eligible employee of your business
• Your employee became injured while at work or became ill due to work conditions

• Stress or other psychiatric injuries
• Self-inflicted injuries
• Injuries caused by fighting or horseplay
• Injuries that happen while commuting to or from work
• Injuries sustained while committing a crime, under the influence of drugs or alcohol, or while violating company policies

It’s important to learn your state’s workers’ compensation laws and follow their requirements regarding the workers’ compensation process. Failure to do so may result in costly fines and penalties.

In addition to keeping an active workers’ compensation insurance policy, make sure you:

• Do provide employees with accurate information on their rights and benefits
• Do report any job injuries in accordance with state deadlines
• Do accurately classify employees and injuries
• Don’t attempt to influence a medical provider’s diagnosis or treatment
• Don’t appeal an approved claim without probable cause