Understanding the Workers’ Compensation Claims Process

A Couple of Caveats

Before we dive into the workers’ compensation claims process, we should address two significant factors that affect it. 

One is the state. Each state has different requirements when it comes to which businesses are required to carry workers’ compensation insurance and other related matters. 

The other factor is the insurance company. A great deal of the workers’ compensation claims process depends on the company. 

In this blog post, we’ll outline the process in broad strokes. However, employers are urged to contact their carriers to learn more about the specifics that apply to them.

What Is a Workers’ Compensation Claim?

A workers’ compensation claim is a claim filed with an insurance company on behalf of an employee who has been injured on the job, while performing a job-related duty, or who has developed a job-related disease. 

Workers’ compensation insurance provides cash benefits and coverage for medical care and may cover the costs of transportation. It also usually covers a percentage of lost wages and provides benefits for survivors if the covered employee is killed.

How to File a Workers’ Compensation Claim

Wondering “how do I file a workers’ compensation claim?” The first step is to complete a workers’ compensation form. The employer should provide this when an employee reports an injury/accident. 

The workers’ compensation claim form is split into two sections – one for the employee and another for the employer. Once the employee fills in their information, including the date, time, place, and circumstances surrounding the injury or disease, they will submit the form to the employer.

Employers must take additional steps during the workers’ compensation claims process. Let’s take a closer look at the most common steps, as well as the overall process.

How to Start a Workers’ Compensation Claim

Beginning a workers’ compensation claim follows a five-step process.

The employee files an injury report. 

We’ve already mentioned the first step, but we’ll cover it again. The employee must report the accident or injury to the employer as soon as possible. 

Most forms request some very specific information from the employee, including general information like their name, address, Social Security number, wage information, and marital status. 

However, the employee should also provide as much information as possible regarding the location, date, and time of the accident/incident.

The employer will then add other information to the report. This should include when the employer received a report of the injury or illness, where the incident occurred on the premises, the type of injury or illness, the part of the body injured, and the cause of the accident. 

Any witness information should be included, too. If possible/applicable, the report should include the name and location of the medical facility where the employee received care, the expected date the employee can return to work, and the number of days the employee is expected to miss from work. 

It is better to submit a partially completed form then to wait extra days until you have verified all the information. The insurance carrier will help the injured worker get the proper treatment for their injuries.

Note: How long after an injury can you claim worker’s compensation? Most states give a defined window of time during which an accident can be reported. 

For instance, Georgia gives employees 30 days to report their injuries to their employer. If you do not report it within the timeframe, you can be fined by the state. It’s usually best to report any injuries as soon as possible.

What’s not covered by workers’ compensation insurance?

Workers’ compensation insurance is designed to cover injuries and illnesses sustained by an employee while carrying out their duties and responsibilities for their employer. As such, it may not cover all situations. 

Those include self-inflicted injuries, injuries sustained through horseplay or fighting, injuries that happen while commuting to or from work, or those sustained while committing a crime. 

In most cases, the insurance company will also not cover injuries sustained while the employee was under the influence of drugs or alcohol or engaged in any activity that violates company policy.

The employer guides the employee in completing additional paperwork.

Filing workers’ compensation insurance claims usually requires completing additional paperwork beyond the initial injury report. 

However, the state in question and the insurance carrier will determine exactly which forms are required and when they must be submitted. The type of injury will also play a role. 

Ideally, employers will provide an overview of the workers’ compensation claims process within new hire packets and the onboarding process. This ensures that employees have access to this critical information from the beginning. 

By working it into the onboarding process and/or required training, employers can also quiz employees to ensure they understand the process and requirements.

The employer files the report with the workers’ compensation insurance company.

In most cases, the employer is responsible for the rest of the workers’ compensation claims process. This requires the employer to submit the injury form and supplemental information to the insurance carrier, but depending on the state, the employer may also be required to submit the information to the state’s department of labor, workers’ comp board, or division of workers’ compensation (different states have different names and requirements – familiarize yourself with what’s required for your state). 

Some of the information the employer must provide includes the following:

• The employer’s account number
• The location code
• The parent company or program name
• The policy number

Depending on the carrier, you may be able to file a workers’ compensation claim online or contact the carrier by phone to begin the process or ask questions about moving forward.

Claim approval or denial.

Once all the paperwork has been filed, the insurance carrier will approve or deny the claim. Approval or denial is based on a wide range of factors. 

If the carrier denies the claim, it’s usually because of insufficient evidence, inaccurate information, or incomplete documentation. 

However, a denial does not necessarily mean that an employee will not be covered. Most of the time, they can request a reconsideration. This is necessary if the denial was due to incomplete documentation or incomplete information.

In the case of insufficient evidence, the employee can usually request a reconsideration if they can provide additional evidence. 

In some cases, the employee may need to file a formal complaint against the insurance company through the state’s worker’s compensation commission/department of labor.

If the claim is approved, the carrier will inform the employee and the employer. The carrier will also provide payment information. 

Depending on their needs, the employee and their attorney may choose to negotiate a lump sum settlement, accept the offer as is, or attempt to negotiate a larger structured settlement.

The employee recovers from their injury/illness and returns to work.

The goal of the workers’ compensation claims process in most cases is to cover the employee’s medical costs and lost wages until they are recovered enough that they can return to the workplace. 

When they are well enough to do so, they’re obligated to inform both their employer and the insurance carrier. 

In this case, a formal return-to-work program can be beneficial. It reduces the amount of time required for an employee to return to work, often by allowing them to perform lighter tasks than their normal responsibilities.

 The program may also include cross-training or retraining to help the employee develop the skills necessary to move into a different position. 

However, if the employee was severely injured, they may be permanently disabled. In these cases, the insurance company will make permanent disability payments that cover a portion of lost wages and medical care and related costs.

Simplifying Workers' Compensation: How Kickstand Can Help

The workers’ compensation claims process can be complicated and drawn out. However, understanding the basic steps to follow can help ensure the best possible outcome and the fewest hurdles for both employees and employers. 

Employers must learn about their state’s specific requirements and their insurance company's workers’ compensation claims process. Those details should also be communicated to employees. 

Failure to follow the process as dictated by the state and insurance company could leave the employer facing fines and penalties. 

Wondering if you need workers’ compensation or if you’re covered by an exemption? Not sure what class codes apply to employees in your specific industry? 

Kickstand can help. Explore our frequently asked questions to learn more. Contact us today or click here to start your instant quote process. 

We work with businesses in most industries to provide critical workers’ compensation coverage. We’re also dedicated to helping you save money while complying with the law and providing your employees with this important protection. We look forward to helping you!