While not as inevitable as death or taxes, any successful and long-running business should be prepared for the possibility of filing a Workers’ Compensation claim. For this entry in our ‘101’ series, Direct WorkComp will take you through the basic steps for filing a claim along with our insights on best practices. In addition, breakdowns on Commercial Audits and the basics of Workers’ Comp can be found here.

As Workers’ Comp laws vary by state, this article will feature some generalities. Contact us directly for any questions regarding your state’s specific regulations.

Step 1 of a Workers’ Comp Claim: Employee Notification, Response and Investigation

Notification: It cannot be overstated how critical it is to instruct employees to report any workplace-related injuries or illnesses immediately. Claims can be denied if an employee does not report their injury to their employer in a timely manner, and the window of time to formally report varies wildly by state. For example, New Hampshire allows two years for an employee injury report while Alabama allows for only five days. Utah gives an employee a generous six-month timeframe; however, workers in South Dakota must report within three business days. What’s more, states like Colorado have set specific reporting timelines for different claim types — workplace injury vs. an occupational disease. Finally, Workers’ Comp boards in some states may require additional injury report forms to be filed within the same deadline. 

Response and Investigation: Immediately following the notification of a workplace injury or illness, it is as important to get the employee prompt medical attention as it is to investigate the cause(s) behind the incident.

• What kind of medical attention does/did the employee need? 
• What were the circumstances and causes behind this incident?  
• Was this a one-off situation or could this be a systemic issue? 
• How can we prevent this from happening again?

A timely, thorough investigation is vital to a successful Workers’ Comp claim down the line.

Step 2 of a Workers’ Comp Claim: Insurance Submission by Employer

As mentioned, it’s important to know and work within reporting timelines and to provide a Workers’ Comp claim form to the affected employee to complete. While employees need to report injuries or illness as soon as possible, employers have a little more leeway when it comes to filing the claim with their insurance provider.

Most states give an employer at least 1-2 years to submit their claim. There are some variations here as well, though. For example, a Maryland employer has 60 days to file a Workers Comp claim in most cases but two years to submit a claim after death or disablement.

While employees need to report an injury or illness to their employer immediately, the employer is the only entity that can submit a Workers’ Comp claim to their carrier. It’s also important to bear in mind that the requirements to file a Workers’ Comp claim can be different on a state-by-state basis. Employee location, nature of the injury and specific insurance company requirements can affect which forms you or the injured party need to complete. 

Confused yet? We understand. Your insurance advisor can help guide you through your specific state’s requirements. We’ve also included state-by-state information for filing a Workers’ Comp claim (but still…check with your advisor to confirm.) 

Step 3 of a Workers’ Comp Claim: Approval or Denial of Claim

After all state- and insurance-related forms have been submitted, your Workers’ Comp carrier will either approve or deny the claim. This is why an initial investigation into the incident or illness is so important — it may ultimately make or break the case. Common reasons for claim denials include the injury not happening at work, the involvement of drugs or alcohol and employee horseplay not related to official job duties. 

As an employer, you also have the right to contest any aspect of an employee’s claim if it doesn’t line up with the report of events. The employee also has the right to contest the insurance carrier’s claim decision or make an official appeal with their state’s Workers’ Comp board if the claim is denied.

If a claim is approved, the insurance provider will notify the employer and then contact the employee for reimbursement of medical and pharmacy bills, disability compensation and/or lost wages. Employees sometimes can negotiate for another kind of lump-sum or structured settlement.

Step 4 of a Workers’ Comp Claim: Moving Forward

Regardless of whether the claim is approved or denied, it’s important to make accommodations for the injured employee’s return to work. It may be necessary to provide job retraining, space for medical equipment or adjustments to workflow procedures. Revisit the initial investigation to ensure the cause of the injury or illness is mitigated as much as possible. 

Even (and especially) in the event an employee can’t return to work, we recommend implementing proactive changes to help prevent future claims. Here are our insights on helping to prevent common workplace injuries.

Final Thoughts on Workers’ Comp Claims

Remember: when it comes to Workers’ Comp insurance claim requirements, “seen one, seen them all” does not apply. Reporting and filing timelines, state laws and the nature of injury can all seriously impact whether a claim is approved or denied. Make sure to work closely with your insurance advisor to prepare for and respond properly to any potential workplace injuries your employees might face.

No matter your state’s requirements, having Workers Comp’ insurance is critical for many businesses. Let DirectWork Comp help find you the right coverage for you and your employees – click here for free quotes!