Workers Comp Software
Incident Report Software >> Workers Compensation Claim Management >> Claim Process
Workers Compensation Claim ProcessA worker is a person employed by a company or institution under the contract of service either on seasonal, commission, full-time, part-time or fixed term basis. It is the responsibility of a worker to ensure reasonable care for their health and safety and also to ensure that their actions or omissions do not pose health or safety harm to other workers. In the case where a worker sustains injury or work-related illness in their line of duty, they should file a claim for compensation. To qualify for reimbursement, an individual should apply within deadlines. Workers compensation is a type of insurance that provides wage replacement and medical care to a worker in case they are not able to work due to an injury or illness attained in the line of duty. In the case where the worker dies in the process, the law requires monetary compensation to the beneficiaries of the deceased. In the event where a worker suffers physical, emotional injury in the line of duty, these are the steps to follow to claim compensation.
Lets start by talking through the steps to follow when making a claim. Each region has its own specific processes and workflows but here are the highlevel steps and processes involved.
First aid and filing a report:First aid is the care given to an injured individual immediately after an injury such that the situation is contained to prevent further damage or worse loss of life before getting access to proper medical attention. After that, it is required to report the incident to the employer.
Seek first certificate of capacity:You are required to see a qualified doctor to issue the first certificate of capacity as soon as possible. This form requires the details of the worker, employment details, description of the injury by the worker, doctor's medical assessment, worker's capacity to proceed with his or her duties and the medical practitioner details. Step Three: obtain and fill out the workers' compensation claim form. It is a claim form where you indicate comprehensive information about the incident, personal details such as name, contacts, address, etc. After filling out the required information sign the worker's declaration section and get a witness to sign as well. You can also opt to append your signature or not on the consent authority section to authorize the employer's insurer to collect your personal information; which is useful in the assessment process of the compensation claim.
Submit the certificate and claim form to the employerBefore submitting the forms ensure to make a copy for yourself for your information and then hand in the original documents to the employer.
Employer to fill in their part on the claim form and submit to the insurerUpon receipt of the claim form, your employer has five working days to fill out and send it together with the certificate of capacity to the insurer.
Insurer assessmentUpon receiving the documents, the insurer has fourteen days to assess the claim and make a judgment: they can either;
- Accept compensation claim: here they start paying your workers' compensation benefits immediately.
- Dispute claim: here the insurer declines to pay your entitlements; you are legally allowed to challenge this decision.
- Pend claim: in this case, the insurer pends the decision when they need additional information concerning the injury or when they require extra time to make a decision. Here the insurer does not pay the entitlements but has ten extra days to review the case and make a decision, within which they will accept or reject the claim. In case of rejection, you can request for a re-examination.
- Salary: as long as the doctor declares you unfit to work, your wages should be paid on the regular payday until you are fit to resume work.
- Medical bills: these include any costs incurred for medical attention; they include doctor's fees, physiotherapy, medication, etc. sometimes there is a limit amount for this cover, ensure that the expenses are within the covered amount to avoid extra costs.
- A lump sum pay-out: where the employer pays a large sum of cash to the worker in case he or she suffers permanent impairment such as amputation, etc.
- Workplace rehabilitation costs: in case an individual requires a specialized work program upon resuming duties, the employer or medical practitioner treating the individual may request for the rehabilitation programme.
- Travel and accommodation: depending on the circumstances where traveling are required, the insurer pays for travel and accommodation.
a) It is your responsibility to attend medical examination per request by the employer with a medical practitioner of their choice.
b) It is your responsibility to comply and participate in your return to work program once it is in place.
c) You have a right to choose your doctor for treatment and a work rehabilitation provider when resuming duties.
a) The employer has the right to ask for medical review through their insurer after the claim.
b) Has the right to contact your doctor to discuss your return to work.
c) Has the responsibility to put an injury management system in place and arrange for the return to work program once you are cleared to resume duties.
d) Following a claim, it is the employer's responsibility to keep your original work position where practicable for up to twelve months.
Understanding the workers' compensation claim process is critical for all workers, such that in case of an injury you will know how to go about it. Having prior knowledge of the claim process will help you avoid unnecessary delays and frustration when filing a claim.
It is necessary to note that different regions have different processes for workers compensation claims. The insights shared above are for general guidance purposes.