Claims Management Techniques in Workers' Compensation Cases

HR Resource
April 17, 2013 — 1,952 views  
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The worker's compensation system is an insurance scheme that covers workplace injury by providing monetary compensation for wage-loss due to inability to work, medical bills, disability and disfigurement benefits, and loss of life. This is in return for the worker waiving his right to sue the employer for the injury. The system is backed by such laws as the OSHA in the USA, and its Canadian counterpart, OHSA.

The system covers injuries caused by workplace accidents, injuries caused by accrued stress, diseases due to workplace conditions, and resulting mental injuries. It generally does not cover injuries caused to self while inebriated, due to negligence of safety protocols, by purposeful misbehavior, and purposeful self-inflicted injuries.

About Claim Management

It is best to take a neutral approach to claim management in case of an on-the-job-injury. It is not advisable to be passive about processing the claim, either to the injured or to the insurer. Nor is it good to be skeptical about claims and take an adversarial approach against the claimant. Both cases result in the claim being neglected, leading to a compounded problem, and ending in large claims and settlements.

The correct way to manage workplace injury claims includes a set of actions focusing on objectivity. Immediately report and investigate claims, while being reasonably communicative and supportive to the claimant. Prioritize disputed claims and claims that might potentially cause further trouble. Finally, find ways to manage your insurers so that claims are processed as fast as possible.

Claim Investigation

It is important to report claims of any on-the-job injury as soon as possible, to both the insurer and the state, if applicable. Claims that are reported at the earliest are the least expensive. Certain accidents and injuries require that the state be informed about them. While states prescribe a relatively long time limit for an employee to report a claim, employers are bound to report claims within a smaller time-frame than employees, barring which, they are subject to fines for reporting late or not reporting. Make sure to give all known factual details of the workplace accident and the claims made.

Claims need to be judged properly, both to eliminate fraudulent claims and to minimize compounding problems. Claims involving certain injuries and medical conditions, and other external conditions like uncertain diagnosis or substance dependency, need to be watched. Suspicious conditions include disability claims close to retirement and the possibility of compensation nearing net earnings, among others.

Settling the Claim

Use your discretion to select the proper medical care for the injured worker, because the right medical help is vital for treating specific injuries, as well as reducing the workers' downtime. Choose a medical facility that is equipped and experienced in treating occupational injuries, preferably as close as possible. Have their staff visit your premises to acquaint the employees of any specific operation being carried out at the workplace, and to help anticipate potential injuries that may result from it. Offer employees the choice of getting treated at a medical facility that knows how to deal with workplace injuries.

Getting the claimant to return to work as soon as possible helps reduce wage-loss indemnity payments. Post treatment, keep a check on the recovery of the claimant and be in touch with the medical staff treating him/her. Keep communications open and offer the worker the choice to return to the same or alternative post.

Pick alternative roles for the worker if he/she cannot resume the same work as prior to the injury. Take the supervisor's opinion on what roles are suited to the worker in his/her present condition and keep targets for all the tasks you assign. Inform the worker of the benefits of returning to work. Consider investing in rehabilitation to get the employee in acceptable shape as soon as possible.

Keep in mind that not all injured workers are cut out from returning to work. It depends on the general health and attitude of the worker, as well as whether his/her wages amount to more than the indemnity payment.

Finally, as an employer, make sure to have your workplace environment strictly regulated according to the safety protocols of OHSA, if you haven’t done so already. This helps to minimize workplace accidents and consequent losses, to both the employer and employee.

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