While most employers take several measures to ensure their employees remain safe, injuries at the workplace or while doing work-related activities are a reality. The injured party has the right to seek compensation for their injuries, while the employer and insurance company have the right to verify the claim is not exaggerated or fraudulent. The process of navigating a workers’ compensation claim can be challenging for all parties involved in the case. While an experienced attorney’s guidance can be invaluable in such cases, it is always best to understand the process so you can make informed decisions about the workers’ compensation claim. This article shares the step-by-step process of navigating a workers’ compensation claim.
Contents
The Employee Reports Their Injury
The first step in most workers’ compensation claims is reporting the injury. The injured employee needs to notify their employer verbally or in writing. The verbal notification might be insufficient, so it is always best to do it in writing, as it helps establish a record. Not all worker’s compensation claims are disputed, but it is always better to have a paper trail in case either party needs to use that as evidence to support their case.
Any delay in reporting the workplace injury can undermine the case for the employee. Depending on state regulations, the injured employee has a limited number of days to report the injury. You can consult a worker’s compensation lawyer to determine how long you have to report the injuries.
Many injured employees make the mistake of not taking their injuries seriously and waiting too long to report them. Delayed reporting also makes it harder to investigate the case, as the longer the time between the accident and reporting, the greater the potential of destroyed evidence, misstatements, and other inaccuracies.
In addition, delayed reporting often leads to litigation, making the case more complex for all parties involved. According to the National Council on Compensation Insurance (NCCI), the probability of a case going to litigation increases to 32% from 13% if the injury is reported after four weeks.
Medical Treatment for the Injured
The medical treatment for the injured employee depends on the severity of the injury; however, getting at least a medical evaluation is often the best course of action for the injured employee. If the injury is not serious, onsite first aid treatment may be all that is needed, but the injured employee should visit a doctor to establish a record.
Your employer may require employees only to get treatment from doctors in their medical provider network. So, it is always best to check the company rules and regulations about receiving medical care.
The worker’s compensation process is often handled by a claims adjuster, who may need evidence of medical treatment. This evidence helps establish the severity of the injuries and the time of the accident. A critical aspect of most cases is demonstrating that the injury qualifies as a workplace injury, and medical evidence can play a key role in this.
The Employer Reports The Injury
After the employee has reported the injury to the employer, it is the responsibility of the employer to report the injury to the worker’s compensation insurer. While each carrier’s requirements can differ, most require the employer to submit information about the employee, injury, and medical care. The employer can work with the injured employee to gather all the required documents.
It is good business practice for the employer to include information about the workers’ compensation claim process in the employee handbook so the employees know their rights and what procedure to follow. In some cases, the injured employee can use the lack of information as evidence of employer negligence.
The employer may also be required to report the injury to the workers’ compensation board. In most cases, the employer has 7 to 10 days to report the injury; however, if a fatality is involved, the reporting time could be reduced. Also, each state has its own laws regarding workplace compensation claims, so it is best to check your state’s laws or consult an attorney to ensure you follow the rules and regulations. The employer may also require the employee to submit a signed fraud statement that contains information about the penalties for making a false claim.
The Claim is Approved or Denied
The worker’s compensation claim can be approved or denied by the insurance provider. When an employee gets injured or sick while working, the worker’s compensation coverage can cover the expenses, but the claim needs to be approved for the coverage to kick in.
The employer pays an insurance premium for this coverage to help protect against workplace injuries. However, workplace compensation may not cover injuries suffered due to self-inflicted incidents or employees injured because of activities against company policies. There could also be other reasons for denial, such as incomplete paperwork, not seeking medical care, not meeting filing deadlines, or an inability to verify the documents that have been submitted.
If the claim is denied, the claimant can appeal or ask the insurance provider to share information about why the claim was denied. The insurer may report the denial to the workers’ compensation board. The employer and employee can seek legal representation to help with an appeal against the denial.
The Injured Employee Returns to Work and The Case is Closed
Before the employee can successfully return to work and the worker’s compensation claim is closed, they must obtain clearance from their medical provider. This ensures the employee is in stable condition to return to work and won’t suffer from a relapse or reoccurrence of the injury. Formal approval from the medical provider is often important to completing the worker’s compensation claim process. The employee and employer should keep copies of the medical clearance in case of any dispute about the issue.
Ideally, the employer and employee should communicate regularly to discuss the return to work. The employer may have to adjust the job or work environment to help the employee transition back to work.
After all the paperwork has been completed and the employee has successfully returned to work, the worker’s compensation claim process can be considered complete, and the case can be closed. In most cases, the employee and employer will sign a final settlement agreement to complete the process.
While the steps mentioned above should help you understand the workers’ compensation claim process, the process can often get complicated, so you might need an experienced lawyer specializing in workers’ compensation claims. While both parties are not required to have separate lawyers, it may be a wise decision as it helps avoid the issue of conflict of interest. The employer and employee can also decide to complete the process without any assistance from an attorney; however, they will have to put in the time and effort required to understand the process and file all the required documents. If you don’t hire an attorney for the entire process, you can have an initial consultation to understand the best course of action and how an attorney can help you with the case.
Disclaimer: 1-800-Injured is an attorney and medical referral service.
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