A Guide on Workers’ Compensation Claim Process

What can be more effective than learning about insurance policies before claim submission? Workers’ compensation claim process is unique as it is an insurance policy that benefits both employees and employers. With the help of workers’ compensation, any employee who had been injured or had met with an accident during the work process, receive benefits to cover expenses like lost wages, medical costs, and more.

Even employers benefit from having complete workers’ compensation coverage accessible to their employees, as it keeps the business from being held responsible to cover the expenses out of pocket. Additionally, it protects the business from any potential legal action taken by the employee. It’s crucial to stay committed assisting the employees throughout to keep them safe, satisfied, and businesses protected.

What is covered under Workers’ Compensation?

  • An injury that occurs related to work or during working hours or during the course of employment will be covered under workers’ compensation.
  • This includes workplace accidents, diseases or illnesses caused due to work situations such as exposure to toxic chemicals.
  • Workers’ compensation covers healthcare provider’s visits, hospital visits, physical therapy, prescription medication, medical equipment, and any out-of-pocket medical expenses.
  • Any other treatments such as chiropractic care got to be pre-approved. The coverage also pays for a percentage of wages lost as a result of an injury or illness but the absence should be related to a work injury, and must be authorized by a medical provider or healthcare professional.
  • Prior to filing a claim, employees or workers must ensure if their company has got a workers’ compensation insurance policy and not an independent contractor. They also must be accurate whether illness or injury had occurred during the work.

How does Workers’ Compensation work?

  • Those employees who were injured during the work are eligible to receive workers’ compensation benefits and the first step in filing a claim is to immediately inform supervisor about the injury or illness.
  • The supervisor must be responsible enough to promptly complete a Supervisor’s Report of Injury or Occupational Illness Form on those documents with the details of the injury.
  • After completing the report, the supervisor sends it to the Office of Risk Management and after Risk Management receives the report, it serves as a formal notice to the insurance company stating that an employee sustained an accidental injury or illness during the work.
  • After the claim is accepted, the claim adjustment service will process disability payments for lost work time.
  • If it’s determined that an employee is not able to return to the pre-injury job after recovering from a work-related injury or illness, the employee might be eligible for vocational rehabilitation services.

What are the injuries that Workers’ Compensation does not cover?

  • Of course, there are few on-the-job injuries that doesn’t cover. They are:
  1. Employees engaging in activities against companies policies such as crime, rivalry, drugs, alcohol etc.
  2. Psychiatric conditions
  3. Self-inflicted incidents
  4. Accidents during commute to or from work.

What if the employee does not lose the work time?

  • When the claim is set up to make payments for any medical expenses related to the injury or illness, the employee should tell the healthcare professional to contact the workers’ compensation claims administrator at the Office of Risk Management for billing information.

If the employee loses work time?

  • If the employee is absent from work, he/she must be authorized by the employee’s healthcare professional or medical provider.
  • The employee should be out of work for three days excluding the day of injury before workers’ compensation gets ready to pay for lost work time.
  • It is an insurance policy to pay an injured employee for the balance of their work shift on the date of injury, and it doesn’t matter on what time the injury occurred or whether the employee returns to work on the same or particular day.

The most important step in Workers’ Compensation claim process?

  • The first and foremost step is the medical treatment for the injured employee. It means receiving an emergency care immediately following the incident or visiting a healthcare professional soon after the injury. Employees will have better chance to recover completely if they seek treatment swiftly.
  • Additionally, employees must have medical records that document their medical procedures to file a workers’ compensation claim through most policies.
  • In case, the injury does not require emergency care, employees must check with their company whether to consult any specific healthcare professional in order to be covered under the workers’ compensation policy.

How does the workers’ compensation claim begin? 

  • Official claim process begins right after the employee has been notified. It typically involves injured employee filling out the required reporting forms provided by the company.
  • These claim forms often vary and are based on the state where the business is based, the type of injury or illness, and the insurance company requirements.
  • Companies are advised to provide policy details or information and forms to new employees while hiring, depending on state or local laws.
  • These forms include essential and critical details such as the nature of the injury, where and when the injury occurred, details surrounding the incident, medical treatment required in relation to the injury, and more.

What happens if the claim is denied?

  • When the claim is denied, healthcare professionals will have the opportunity to appeal or ask the insurance company to review their decision.
  • The insurance company will report their requirements to the workers’ compensation board, depending on the state laws. If needed, the employee can seek legal representation.

What happens if a claim is approved?

  • When a claim is approved, employees will be notified regarding their compensation that cover costs including medical expenses, disability, lost wages, and more.
  • The employee will be given an opportunity to accept the compensation amount either at one settlement or a structured one.
  • They can also choose to seek legal representation if they wish to negotiate payments for larger amount.

Hope you got required information on workers’ compensation. For any queries and suggestions please comment below. Do subscribe our blog for further updates on healthcare.




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