WCG Claims
If you have specific questions about the workers' compensation process that are not covered by the following information, please call your representative at York Insurance Services.
How does the workers' comp process begin?
What constitutes notice of a workers' comp claim?
When knowledge of injury/illness is received, what are the paperwork steps?
Where does the employee receive medical treatment?
Can an employee use his/her own medical doctor for treatment of an injury or illness?
When can the employee return to work?
Does the employer have to take an employee back for limited duty?
Who pays for any doctor bill, hospitalization charges, ambulance fees, and/or medication that result from the injury/illness?
When does an employee begin to receive his workers' comp disability payments?
Are workers' comp injuries always accepted as job related and benefits provided to the employee?
If I know that the employee is faking or was injured off the job, what can I do?
If the employee is off work, what can I do to get him/her back?
Does the employee have the right to an attorney in workers' comp cases?
What can I do about follow-up treatment or evaluations for accepted workers' comp claims?
Why must an employee talk to a rehabilitation counselor if he/she is going to return to work?
When can I replace an employee if he/she cannot return to work because of the workers' comp injury?
What are some of the benefits due an employee who is injured at work?
How are cases closed in the workers' comp system?
How does the workers' comp process begin?
The process begins when the employer is made aware of an injury, illness, or death of an employee that is the result of the employee's work.
What constitutes notice of a workers' comp claim?
A claim is created when an employee suffers a work-related injury, illness, or death and the employer is notified by one of the following:
- Employee tells supervisor of the incident;
- Employee tells another employee of the incident;
- Another employee observes injury and tells supervisor of the incident;
- Employee's supervisor observes an incident;
- The employee's legal representative files a claim with the employer.
When knowledge of injury/illness is received, what are the paperwork steps?
If there is no lost time and no doctor visit:
- Employer's internal accident/incident report should be completed within 48 hours of knowledge, to be kept in the supervisor's personnel file.
- If requested by the injured employee, the Workers' Compensation Employee Claim Form (DWC-1) should be provided to the employee within 24 hours of the request (provided by mail or in person) with verification this has been done through a "Proof of Service" form or other formal verification process.
If there is lost time and/or a doctor's visit:
- Employer's accident/incident report should be completed within 48 hours of knowledge.
- Employee Claim Form should be provided to injured employee within 24 hours of knowledge of injury (provided by mail or in person) with verification this has been done through a "Proof of Service" form or other formal verification process.
- Employer's First Report of Injury (5020) should be completed within twenty- four (24) hours of knowledge of injury.
- The Employer's First Report and Employee's Claim Form should be sent to Gregory B. Bragg & Associates immediately upon completion.
Where does the employee receive medical treatment?
- In the case of serious life-threatening injury or illness, the nearest emergency room medical facility.
- In the case of an ambulatory, non-life-threatening injury or illness, the nearest employer designated occupational medical facility.
- If there is a chance of causing more serious injury or illness due to staff moving the injured employee, an ambulance should be called and notified that this is a workers' compensation injury.
Can an employee use his/her own medical doctor for treatment of an injury or illness?
- For preliminary treatment, only if the employee has signed a request prior to the injury/illness and that request is in the employee's personnel file.
- Thirty (30) days after the initial injury/illness the employee may request a change of treating physicians through the claims examiner.
When can the employee return to work?
- Following the receipt of treatment by the doctor, the doctor should provide the employee with a return-to-work slip, which will tell the supervisor if the employee can return to work and under what conditions.
- If the return-to-work slip is unclear as to the conditions under which an employee can return, the supervisor should call the claims examiner for clarification. The employee should not be returned to work until clarification is received.
Does the employer have to take an employee back for limited duty?
The employer can review the conditions of return to work from the doctor. If the employer can't accommodate those conditions without further aggravating the injury/illness, the employer does not have to bring the employee back until work is available that would not aggravate the injury/illness. If a limited duty program is created, it must be offered equally to all workers' comp injured workers in the specific job classification.
Who pays for any doctor bill, hospitalization charges, ambulance fees, and/or medication that result from the injury/illness?
- If the injury/illness is accepted as a legitimate workers' comp claim, then the employer, through the claims administrator, pays these expenses for the employee.
- If the claim is accepted and the employee receives a bill for the above services, the supervisor should obtain the bill and send it to the claims examiner for payment.
When does an employee begin to receive his workers' comp disability payments?
- If an employee is off more than three calendar days due to a workers' comp injury/illness, he/she will begin receiving workers' comp temporary disability payments with his/her normal paycheck. These payments may be supplemented with an employee's accrued sick leave and vacation to provide a full paycheck. The supplemental payments are not tax-free.
- Police officers and firemen receive full pay, tax-free from the first day of disability for up to one year.
- If an employee runs out of supplements, he/she will continue to receive the temporary disability payments as long as he/she is off work and eligible for the benefits.
Are workers' comp injuries always accepted as job related and benefits provided to the employee?
No. There are three notices that can be sent to an employee regarding their workers' comp claim. The first notice is that the claim is accepted. The second notice states the claim is delayed for up to 90 days pending the receipt of more information to determine whether or not the claim arose out of the employment. The third notice states that the claim is denied as not being work related and no benefits will be provided. If the acceptance of a claim is delayed and later accepted, then all benefits due to the employee, from the date of injury, will be provided.
If I know that the employee is faking or was injured off the job, what can I do?
If you are aware of the possibility that this is not a work-related injury, contact the claims examiner and provide him/her with the information you have. An investigation will be conducted and the claim will be reviewed to see if it is a valid claim.
If the employee is off work, what can I do to get him/her back?
Once a doctor takes an employee off work for a workers' comp injury/illness, it takes a doctor's statement to bring the employee back to full or limited duty. If you have knowledge that the employee is doing similar work while off, contact the claims examiner and he/she will investigate the matter, including talking to the doctor about returning the employee to duty.
Does the employee have the right to an attorney in workers' comp cases?
Yes. The benefits are very specific in the law; however, some employees want an attorney to represent them. Once a settlement is reached in the case, the attorney gets a certain percentage of the employee's settlement. If you know an employee has an attorney, you should not discuss the details of the case with the employee. You can discuss how the employee is feeling and when the doctor may allow them back to work and/or whether they have future medical appointments.
What can I do about follow-up treatment or evaluations for accepted workers' comp claims?
The employee has the right to any follow-up treatment or evaluation ordered by a physician. They will be paid mileage to and from the doctor's office. If the employee has returned to work and has treatment or an evaluation, you can request that he/she schedule the treatment at the beginning or ending of a shift to reduce disruption to the work site. The employee will not receive a temporary disability payment for treatment or a follow-up evaluation unless the treatment requires that the employee miss his/her entire normal work shift.
Why must an employee talk to a rehabilitation counselor if he/she is going to return to work?
Under the current workers' comp law, if an employee is off work more than 90 days, even if he/she will be returning to work, a rehabilitation counselor must be assigned to the case. The counselor must speak with the employee about the potential of rehabilitation. It does not mean that the employee can no longer work at his/her old job. It also does not mean the employee must be rehabilitated.
When can I replace an employee if he/she cannot return to work because of the workers' comp injury?
- Generally, once a doctor has declared the employee's condition to be permanent and stationary (P&S) and has defined the conditions of work, which preclude the employee from returning to work, you can replace the employee. However, before taking any action, you should check with your personnel department and York Insurance Services.
- Under recent Federal Law established through the Americans with Disabilities Act (PL 101-336), an employer is required to try and make "reasonable accommodations" for an injured employee trying to return to work. Reasonable accommodation should be explored and documented before making a final decision to release/replace an employee.
What are some of the benefits due an employee who is injured at work?
If the claim is accepted as legitimate, the following are some of the benefits:
- The employee's injury/illness-related medical bills and transportation will be paid.
- If the employee misses work, he/she will receive tax-free temporary disability payments until the employee returns to work, is retired, or the case is closed.
- If the employee cannot return to his/her normal job, rehabilitation services will be offered which will either place him/her in another job or will provide training and replacement in another job. While in rehabilitation, the employee will receive vocational rehabilitation temporary disability (VRMA) payments.
- The employee may be eligible for a cash payment for permanent disability if it is found that the employee has suffered some percentage of permanent disability due to the injury. The amount of the payment is determined by medical statements about the degree of permanent disability by a physician, and the use of a State mandated rating system.
- If the employee dies due to a work-related injury, there are specific burial and death benefits provided to his/her dependents.
How are cases closed in the workers’ comp system?
There are three ways in which a case can be closed:
- The injury/illness is resolved with no permanent disability, the employee returns to work, and the matter is closed.
- The case can be closed with a Stipulation. This means everyone agrees to the nature of the injury/illness, the level of benefits (i.e. rehab, PD, etc.), and future medical care, if any.
- If there is no agreement or compromise on the injury, its severity, and/or level of benefits, the matter goes before a Workers’ Compensation Appeals Board Judge who hears the case and then determines the type or level of injury and benefits, if any are to be awarded.
- The third type of closure is in between. There may be a dispute on injury level of benefits or other case-related benefits. Rather than go before the Judge, the matter is Compromised and Released (C&R) to avoid the cost of litigation. This usually represents some form of compromise with neither side admitting to any guilt or responsibility in the case and provides a specific amount of benefits with no future medical benefits provided.