Workers’ Compensation Insurance
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What is the workers’ compensation claims process?

When your employee suffers a work-related injury or illness, there are several steps you must take to get the workers' comp claim filed and benefits approved.

How does the workers’ compensation claim process work?

Following an on-the-job injury or work-related illness, there’s a limited amount of time to report the injury and file a claim. Failure to do so could result in a denial of workers’ compensation insurance benefits.

That’s why it’s important that employers train their employees to immediately report an injury at work. As the employer, you’re typically responsible for submitting a claim to your workers’ compensation insurer, but you’ll first need to gather details and documentation about the incident.

Once you’ve learned of an employee’s injury, your first step should be to instruct your employee to seek medical treatment if they haven’t already. To get the claims process rolling, you’ll need to:

  • Give your employee the appropriate paperwork to fill out regarding the date, time, place, and circumstances of the injury.
  • Interview witnesses as appropriate and include their statements in your supporting documentation for the claim.
  • File the completed form and supporting claim documentation with your insurer.
  • Submit a first report of injury form to your state’s workers’ compensation board if required.

Workers’ compensation laws vary by state, so be sure to check your state’s rules and deadlines to assure you’re in compliance.

5 steps to filing a workers’ comp claim

While the workers’ compensation claims process can seem complicated, it can be broken down into five basic steps.

1. The employee reports an injury to their employer

As an employer, make sure your employees know that if they become ill or injured on the job, they need to inform you as soon as they are able. Typically an injured employee is required to provide written notice, and most states set deadlines for reporting injuries. For example, the employer must be notified within 30 days in New York, while other states allow employees a year or more to report an injury.

A variety of injuries may qualify, such as slipping on a wet floor in the office and breaking an arm, or developing carpal tunnel syndrome from repetitive typing.

Some injuries may require immediate treatment at an emergency room or urgent care. Others may require a doctor’s visit for diagnosis and medical care. Depending on the state and the insurer, the employee may need to seek non-emergency treatment from a medical provider that’s part of the insurer’s network in order to receive benefits.

With injuries or illnesses that surface over time, such as mesothelioma (caused by exposure to asbestos), the employee should report the illness as soon as possible.

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2. The employer guides the injured worker on necessary paperwork and next steps

Once you’ve been notified of an employee injury, you’ll need to provide your injured worker with information on their rights and workers’ comp benefits, as well as their return to work. In most states, you’ll give your employee a workers’ comp claim form to fill out and return to you. This form will detail the nature of their injury, along with where, when, and how it occurred. You may also need to have your injured employee fill out a first report of injury form that you’ll submit to your state’s workers’ compensation board.

Which forms are required and who is responsible for completing them depends on the state where you and your employee are based, the type of illness or injury, and the insurer.

It’s a good business practice to include workers' comp insurance information in your new hire employment packet to assure your employees know their rights if they’re injured on the job. If you fail to provide this information, you could face a lawsuit.

3. The employer reports the injury and files the claim form

Usually, the employer is responsible for sending the claim form and all supporting documentation to the workers’ comp insurance carrier, but the employee’s doctor will also need to submit a medical report.

Additionally, you may be required to report the injury to your state's division of workers' compensation or workers' comp board. This may apply for all workplace injuries, even if your employee is not seeking workers’ comp benefits.

4. The insurer approves or denies the claim

Once the claim is filed, the insurer will either approve or deny the claim.

If a claim is approved:

Once a claim is approved, the insurer will inform the employer and contact the employee with payment details. At this point, the employee and their workers’ compensation lawyer (if any) may:

  • Accept the insurance company’s payment offer, which may cover the costs of medical bills, medicine, disability payments, and a portion of lost wages
  • Negotiate for a lump-sum settlement or larger structured settlement

If a claim is denied:

If your workers’ comp insurer denies benefits, the employee has the option to:

  • Request a reconsideration from the insurance carrier
  • File a formal appeal, usually through the state workers’ comp board or commission

5. The employee returns to work

Once an employee has recovered from an injury and is able to return to work, they’re required to provide written notice to both their employer and the insurance. Depending on the severity of the injury, the insurance company may have to pay permanent disability benefits.

Many employers choose to implement a formal return to work program, aimed at getting workers back to work and productive as quickly as possible. These programs may involve offering an injured worker modified duties, or training employees on other skills if they’re unable to resume their regular responsibilities.

When should you file a workers’ comp claim?

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.

In order 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.

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 sustained while committing a crime, under the influence of drugs or alcohol, or while violating company policies

It’s important for business owners to follow the workers’ compensation claim process

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 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

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.

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