What is the workers’ compensation claims process?
For an injured employee to receive benefits, the worker needs to follow the workers’ compensation claims process, including filing a claim before the state deadline.
How does the workers’ compensation claim process work?
If a worker is injured on the job, there is a limited amount of time to submit paperwork in order to receive workers’ compensation benefits. Both the worker and the employer must act promptly when an injury occurs. 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 it occurred)
- File a formal workers’ comp claim
The workers' compensation process can vary depending on where the employee is located since workers’ comp is regulated by the state.
When should an employee file a workers’ comp claim?
An employee should file a workers’ compensation claim if injuries were sustained 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.
In order to file a claim, all of the following must be true:
- The employer has a workers’ compensation policy.
- The injured worker is an employee of the business, not a contractor.
- The employee became injured while at work.
Workers’ comp typically won’t cover:
- Stress or other psychiatric injuries
- Self-inflicted injuries
- Injuries caused by fighting or horseplay
- Injuries that happen while commuting to or from work
- Injuries incurred while committing a crime, while under the influence of drugs or alcohol, or while violating company policies
How to file a workers’ comp claim:
1. The employee reports an injury to the employer
To make a workers' comp claim, the employee's injury or illness must be work-related. A variety of injuries may qualify, such as slipping on an icy patch in the business parking lot or developing cancer from exposure to toxic substances in the workplace.
In emergency situations, the employee should be rushed to a hospital emergency room. For less immediate concerns, injured workers should go to a doctor to get a diagnosis and receive a medical report to file with the workers’ comp claim.
Depending on the state and the insurer, the employee may need to visit a medical provider that’s part of the insurer’s network to receive benefits.
The employee should provide written notice of the injury as soon as possible. Reporting deadlines vary by state. For example, the employer must be notified within 30 days in New York, while other states allow employees up to a year or two to report the injury.
With injuries or illnesses that surface over time, such as mesothelioma (caused by exposure to asbestos), the employee should report the illness as soon symptoms occur.
2. The employer provides the necessary paperwork to the employee
Once the employer has been notified about the injury, the employer should give the employee:
- The proper reporting forms for the workers’ comp insurance provider
- A form for reporting to the state workers’ comp board (depending on state law)
- Information on the employee’s rights and workers’ comp benefits
- Information about returning to work
The forms the employer will need to provide to the employee will depend on the state where the employer and employee are based, the type of illness or injury, and the insurer.
If possible, employers should provide this information before the injured employee seeks treatment. Some businesses include workers' comp insurance information in the employment packet for new hires. Failure to provide this information to injured employees could lead to lawsuits.
3. The employer files the claim
Usually, the employer is responsible for submitting the paperwork to the workers’ comp insurance carrier, but the employee’s doctor also needs to mail a medical report.
Additionally, employers may need to submit documentation to the state workers' compensation board. This may apply for all workplace injuries, even if the employee is not seeking workers’ comp benefits.
4. The insurer approves or denies the claim
Once the claim is filed, the insurer will make a determination. If the claim is approved, the insurer will contact the employee for payment detail. If the insurer doesn’t think the claim qualifies for workers’ compensation benefits, it will be denied.
The rest of the process is between the employee and his or her legal representation (if any), doctors, and the insurance company.
If the insurer approves the claim, the employee can:
- 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:
- The employee can ask the insurance company to review the decision
- The employee can appeal
In both instances, the insurance provider will notify the workers’ comp board of its decision.
5. The employee returns to work
The employee must notify both the employer and insurance company via written notice when he or she has recovered sufficiently and wishes to return to work. Depending on the severity of the injury, the insurance company may continue paying disability benefits.
If employees continue to experience occupational injuries, a company’s workers’ comp premium may increase. To avoid injuries and premium increases, employers should provide adequate safety training to ensure workers can perform job duties in a safe manner.
It’s important for business owners to follow the workers’ compensation claim process
Failure to follow any of these steps with your state’s mandated workers’ comp claims process can result in fines:
If you need workers’ comp coverage for your employees, compare quotes online with Insureon today to avoid penalties and business risks. Most small business can get workers’ comp coverage in 24 hours, depending on the state.