Effective Claims Handling For The Employer

Sunday, September 12, 2004 | 0

This second article in a series for employers on understanding work comp and what to do deals with employer obligations, and efficiency suggestions, when a work injury occurs. The first article introduced terms of art to help in the understanding of work comp jargon, necessary to an understanding on how the system works. Earlier articles in the series can be accessed by clicking on the title in the side bar at right.

by Brent Heurter

Workers' compensation claims can become very expensive when not handled effectively. Following these basic steps may be helpful:

1. Provide initial and periodic employee orientation regarding the reporting of any work-related injuries or illnesses in a timely fashion. Compel employees to promptly report work-related injuries or illnesses.

2. Mandate supervisors to immediately report work-related injuries or illnesses.

3. Implement a supervisor's accident report form.

4. Documentation may provide a basis for further investigating the claim and contesting a fraudulent claim, and establish third.party liability.

5. Establish communication with the WC carrier. Insist that they expedite processing of claims, medical treatment, and benefits.

6. Identify the medical clinic; hospital and doctors to whom you will be referring injured employees. Include every conceivable specialty that may be needed, given the work environment, e.g., ophthalmologist, orthopedic, chiropractic, etc. Establish your protocol with each entity so that all matters are handled according to your instructions.

7. Medical treatment must be provided promptly to injured employees. Employers have medical control for the first 30 days, unless the employee previously designated his own personal doctor.

8. Establishing a transitional work program (modified duty). The program must be closely monitored.

9. File form 5020 within 24 hours, for every injury other than first aid, with their WC carrier.

10.Additionally, employers are required under LC section 6409 to report each injury, which results in lost time or medical treatment beyond first aid to the CalOSHA within 8 hours.

When an Injury Occurs

When an employer learns that a job.related injury has occurred, the employer has multiple duties:

1. Provide emergency medical care when necessary

- An employee injured on the job has the right to "medical, surgical, chiropractic and hospital treatment, including nursing, medications, medical and surgical supplies, crutches and apparatus, including artificial member..." Included within the scope of this statute are physical therapy and diagnostic testing.

- To meet the obligation to furnish medical care, the employer or insurance carrier has the right to establish a medical provider network (starting 1/1/05). If the employer does not have a medical provider network, the employer may designate the physician who will provide medical treatment only for the first 30 days after an injury is reported, where the employee has not furnished the employer preinjury written notice of the employee's selection of a personal physician, or where the employee's personal physician refuses to provide medical treatment because a different medical specialty is required.

2. Furnish to the employee the "Employee's Claim Form for Workers' Compensation Benefits" (DWC Form 1). An employer must furnish this claim form if the injury results in medical treatment beyond "first aid" or in any lost time beyond the date of injury.

- Failure on the part of the employee to complete and return the claim form to the employer does not relieve the employer of the obligation to report the injury and its surrounding circumstances to the insurance company as soon as possible; nor does this mean that the insurance company can ignore the provisions governing the timely payment of benefits if a jobrelated injury has occurred.

- Under LC section 5405, an employee must file a workers' compensation claim within one year of the date of injury. Galloway v. WCAB, 63 Cal.App.4th 880 (1998)

- A California court of appeals has held that an injured worker who was not informed of his workers' compensation rights by his employer could file a claim past the one.year statute of limitations. In this case, the employer failed to give written notice to the employee of his workers' compensation benefits after it learned of the injury.

3. Conduct an investigation into the surrounding circumstances and document any findings. Information obtained through this investigation often can be used to prevent similar injuries in the future.

- Such investigations should include interviews with co-workers and other witnesses, and the securing of any circumstantial evidence including machinery, products, ladders and hand tools that may have been involved in the injury.

4. File the "Employer's First Report of Occupational Injury or Illness" (DLSR Form 5020) with the insurance company. This form should be filed as soon as possible but not later than three days after the injury occurs if the employee misses more than one day of work, requires hospitalization of more than 24 hours, or more than first aid is required.

5. Communicate with the employee, focusing on his/her recovery from the injury and return to work. The employee should be informed of benefits he/she may be eligible for and when the benefit or services will be furnished. In addition, the employee should be asked about relevant circumstances relating to the injury, including the names of witnesses, and for any suggestions on how the injury could have been prevented.

6. Take corrective action to eliminate any workplace hazards that may have been discovered as a result of the injury or the investigation.

When an Injury Is Disabling

A disabled worker is entitled to receive a benefit check within 14 days after the date of injury and every two weeks thereafter. Temporary disability (TD) benefits are not paid for the first 3 days an employee has missed work unless the employee is hospitalized as an "in-patient" for medical treatment, or if the employee's disability continues for more than 14 calendar days as a result of the injury.

Employers must ensure that the employee is receiving benefit payments in a timely manner and is kept informed of his/her status. Make certain your insurance carrier has mailed the first disability payment or has given the employee written notice of his/her benefit status. Also make sure the employee knows of the company's interest in his/her return to work. This is known as an Injury Management Program.

Additionally, contact on the disabled worker periodically to assure that he/she is satisfied with the medical treatment being provided. An employee who is not receiving benefits for a legitimate job-related injury, or is unhappy with the medical care is more likely to obtain an attorney to litigate his claim.

by Brent Heurter, Founder and Chief Solutions Officer of ClearComp, a workers' compensation alternative for companies that desire to control and reduce their workers' compensation costs. Brent can be reached at 888.CLEAR.89 or email brent@clearcomp.com.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.