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Workers' Comp Claims Checklist

Workers Comp Checklist Header

Workers' compensation insurance provides important medical and wage benefits to employees who become ill or get hurt on the job. This coverage also protects your business against civil lawsuits if someone who works for you experiences a workplace injury or illness. Every state is different when it comes to workers' compensation and what's required.

Private employers reported 2.7 million nonfatal workplace injuries and illnesses in 2020, according to the Bureau of Labor Statistics. Ideally, your employees remain healthy and whole but understanding the workers' comp claim process is important nonetheless.

How Do Workers' Compensation Claims Work?

Workers' compensation insurance provides employees with a set time frame in which they can file a claim with their employer. As the business owner, it would be up to you to forward this claim to your workers' compensation insurer. Once this claim is filed, the insurance company will review the details of the employee's injury or illness and make a determination regarding the claim.

So when should a workers' compensation claim be filed?

Generally, any injuries or illnesses that occur within the scope of employment qualify for workers' compensation benefits. You must have a workers' compensation policy in place for a claim to be filed and the person injured must be an eligible employee. Classifying workers as independent contractors may not excuse you from providing them with coverage if your state's employment commission or labor board determines that they are employees.

Certain types of illness or injuries may be excluded from coverage. That includes injuries that are self-inflicted, injuries sustained while the employee was driving to or from work, injuries or illness related to stress and injuries or illnesses that occurred while the employee was committing a crime or doing something that violates company policy. A thorough investigation is necessary in order to determine if in fact a claim would be deemed non-compensable.

What to Do If an Employee Is Hurt or Ill

The workers' comp claim process includes some specific steps that both you and your employee need to take to ensure that a claim filing goes smoothly. Having a written process or timeline for employees to follow can be helpful to avoid confusion or potentially costly mistakes.

Here are the most important steps to include in a written procedure for employees.

Step 1: Report and assess the injury (Timing: Immediately)

Employees should be aware that they must report injuries they suffer to their supervisor right away. This allows time for the injury to be assessed and determine whether medical treatment is necessary.

If you have a workers' compensation policy with Westfield, you can direct your employee to call the 24/7 nurse triage line at 844-380-2743 if they're hurt. A registered nurse will:

  • Evaluate the worker's symptoms and injuries
  • Determine the best treatment option, based on their medical situation
  • Coordinate with in-network medical providers
  • Report the claim to Westfield
  • Follow up with the employee within 24 to 48 hours to ensure they're seeking appropriate care
  • Send documentation to help the worker with post-appointment communication so they can get back to work

This can save you and the employee precious time by streamlining the workers' comp claim process. It can also help to cut down on unnecessary emergency room visits as a nurse can determine whether an injury or illness requires a trip to the ER.

Step 2: File a claim (Timing: As soon as possible after injury assessment)

Once the injury is assessed and treatment rendered, if necessary, employees should next be directed to file a claim. Employees should be aware that they have a specific time limit in which to do so. This time limit can vary by state.

In California, for example, employees must report an injury within 30 days to avoid losing their right to receive workers' compensation benefits. In Arizona, however, workers have up to one year from the date of the injury or illness to file a claim for benefits. As part of your written policy, employees should know when the cutoff date is for filing a claim to avoid losing their workers' comp benefits.

Step 3: Document the injury (Timing: After the claim is filed)

Documentation can be central to an employee's workers' compensation claim. As the employer, it can be helpful to take photos of the injury and the area where the injury occurred as soon as possible. When photographing the scene of the injury, look for anything that may have contributed to it such as wet floors, exposed electrical cords or obstacles that may have caused an employee to trip and fall.

It's also important to have the employee complete an incident report as soon as they're physically able to. Your written policy should include an accident investigation timeline that employees should follow to capture the details of what happened when they were injured. Your policy should also specify what form is used to complete the report, the deadline for completion and to whom it should be submitted.

The employee should be aware that they'll need to share specific details about the injury, including:

  • Date and time of the injury
  • Nature of the injury
  • What happened, in detail
  • Names of individuals who witnessed the injury, if applicable

The employee's supervisor will also need to fill out an incident report as part of the company's accident investigation. Witnesses will need to be interviewed and provide a statement about what they observed when the accident occurred. This can help you to clarify what happened while identifying any potential hazards that need to be addressed to prevent additional injuries.

Step 4: Finalize the claim (Timing: Varies)

The resolution process for workers' compensation claims can take several weeks or several months, depending on the severity of the claim. If a claim is denied, the employee should also be aware of their right to request reconsideration or file an appeal. The appeal may go to the state workers' compensation commission or board, which can extend the claims process.

Step 5: Return to work (Timing: After the claim is finalized)

Once an employee is approved to return to work, they'll have to provide you with written notice from an employer-authorized physician that they're medically cleared to do so. You then have to determine whether to return them at their previous capacity or modify their duties and/or working hours to accommodate them if they're not able to resume their regular responsibilities.

Your workers' compensation policy should include guidelines for determining what duties an employee will or will not complete upon their return. Your policy can also outline what steps an employee should take if their injury prevents them from carrying out their duties. This should also include a communication policy for notifying you about related doctor appointments and return to work statuses.

Minimize Workers' Comp Headaches

Navigating the workers' comp claim process can seem overwhelming but it's important to have a clear plan in place for employees to follow. That means ensuring they understand the following:

  • What their rights are regarding workers' compensation insurance and claims
  • What types of injuries or illnesses they're required to report
  • When injuries or illnesses should be reported to you and how to report them
  • How to file and document their claim (i.e. photos, incident report, etc.)
  • What their options are for returning to work once a claim has been accepted or denied

It's important to find a cost-effective option that's tailored to your particular needs. That's where an independent insurance agent can help. Connect with a Westfield agent today to discuss what would work best for your business.