Workers Compensation Claims

There are four basic steps involved when an employee is injured on the job and needs to file a claim:

• Injured employee should notify the employer or supervisor immediately. 

  • A First Report of Injury will need to be completed to open a claim with the insurance carrier.

  • This form describes the nature of the injury and the basic employee information.

  • Click Here to see an example of a First Report of Injury or Illness Acord Form.

• Visit a doctor and determine extent of injury or illness.  If its an emergency, get medical attention immediately.

  • It is extremely helpful to have the insurance company name and policy number for the medical facility.

• Employers should contact the insurance company as soon as practical to notify them about the injury and claim.

  • The sooner the carrier is informed the better they can assist with claims processing and consultation.

• Employer should provide the First Report of Injury Form the the insurance company's claim department.

  • The carrier will typically notify the applicable state department and guide the rest of the claim process.

Most statutes require employees to notify employers of their injuries within a certain number of days after the accident. Persons acting on behalf of an employee may provide this notice to the employer. Some states require employees to notify the state industrial commission as well.  Typically, your insurance company will do this as required by law.

Although many statutes prescribe a certain period (i.e. 90 days) within which the notice must be given, others make general statements such as "as soon as practicable".  Sometimes, the notice provisions do not apply to death claims. Furthermore, if a worker is mentally incompetent or incapacitated because of his injuries, he or she is generally excused from the notice requirements.

Statutory notice does not have to be given in any particular manner.  Some statutes, however, require that the notice be written. These requirements are not always enforced.  Sometimes, the notice requirement may be waived.  The First Report of Injury may serves this same purpose.

Once an employer has been notified of a work-related injury or death, it will typically notify its workers' compensation insurer. If the employer and its carrier accept liability for the injury, a notice of compensation payable will be issued to the employee.

If the employer and the insurer deny coverage on the claim, the employee may file a claim with the proper state agency. All workers' compensation statutes restrict the amount of time an employee or a dependent has to file a workers' compensation claim. Although the periods vary from state to state, they generally range from one to three years from the date of the injury. In the case of an occupational disease, the limitations periods may begin to run when the employee realizes that he or she has the disease.

Once a claim is decided, parties have rights to appeal. Such appeals may continue all the way to the state supreme court.

Click Here to learn about the types of benefits paid by insurance companies.

Definitions:

What constitutes a workers' compensation claim?

• A claim is filed by an individual or corporation to recover losses under an insurance policy.  Claims are referred to the insurance company for handling on behalf of the insured in accordance with the policy terms.

• A claim is also referred to as a loss appearing on a loss report, identified by claim number or appearing as "number of claims." (the terms "claim" and "loss" are synonymous.)

Loss:

• The basis for a claim for indemnity or damages as the result of an injury or occurrence under the terms of an insurance policy.

• The amount an insurer is required to pay as a result of an occurrence against which it was insured.

Loss Ratio:

The ratio, expressed as a percentage, of total incurred losses to total earned premiums in a given period.

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