Workers Compensation Claims _________________________ Key Elements - PDF document

9/19/2017 Workers’ Compensation Claims _________________________ Key Elements Determining Reporting Injured worker compensability a claim benefits Dispute Subrogation resolution Employer Network Best Resources Options – Practices In or Out Reporting a Claim 1

9/19/2017 Report a Claim Through One of These Methods:  DWC – 1 : Employer’s first report of injury • Some carriers offer online reporting  DWC – 41 : Employee’s notice of injury  Notice from DWC  Medical report  Any other correspondence that informs the carrier of a potential work-related injury. Determining Compensability Determining Compensability Injury MUST: • Occur at work • Be caused by work 2

9/19/2017 Determining Compensability Compensable vs Non-compensable Most claims are compensable A small percentage are disputed Non-compensable Injuries  Intoxication  Horseplay  Intentional injury  Third-party for personal reasons  Off-duty activities  Acts of God Injured Worker Benefits 3

9/19/2017 Injured Worker Benefits Income Benefits:  Temporary (TIBs) Monetary  Impairment (IIBs)  Supplemental (SIBs) Injured Worker Benefits Other Benefits Medical Death Burial Dispute Resolution 4

9/19/2017 Dispute Resolution  Administrative Process • Benefit review conference (BRC) o Binding arbitration • Contested case hearing (CCH) • Appeals panel  Judicial Review Subrogation Subrogation Injury caused by a negligent third party Employee Carrier pays sues workers’ comp responsible benefits party Policyholder Carrier loss run asserts lien or benefits from joins lawsuit success 5

9/19/2017 Employer Best Practices Employer Best Practices  Complete first report of injury  Employer RTW best practices  Arrange prompt medical treatment  Report wages  Report change in work status If an Injury Occurs Complete First Report of Injury (DWC-1) Interview worker File no later than Contact and witnesses – 8 th day after lost OSHA Get written time begins statements Within 8 hours for fatality of accident resulting in hospitalization of three or more workers 6

9/19/2017 Medical Treatment • Arrange for prompt medical treatment o Network – visit texasmutual.com o Non-network – choose any doctor • Obtain timely post-accident drug screen Return to Work  Provide bona fide offer • Obtain work restrictions (DWC-73) • Develop modified duty (DWC-74 optional) • Obtain sample letter • Present by verifiable means with (DWC-73)  New offer needed if restrictions change Reporting Wages Wage Statement Pointers Filed within 30 days after lost time begins Gross earnings Don’t include or exceed date of injury Both pecuniary (monetary) and non-pecuniary wages File supplemental report if changes occur 7

9/19/2017 Change in Employee Status  Call your adjuster ASAP with the effective date  File complete supplemental report of injury (DWC-6) with the carrier Network Options: In or Out? Network Options: In or Out? Factors to Consider Discount for Employer network responsibilities participation Employee Access to care responsibilities 8

9/19/2017 Policyholder Resources Texasmutual.com Tools Texasmutual.com Tools 9

9/19/2017 Questions? Thank you! 10