Workers Compensation Claims _________________________ Key Elements - - PDF document

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Workers Compensation Claims _________________________ Key Elements - - PDF document

Sep 05, 2023 180 likes •290 views

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

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9/19/2017 1

Workers’ Compensation Claims

_________________________

Key Elements

Reporting a claim Determining compensability Injured worker benefits Dispute resolution Subrogation Employer Best Practices Network Options – In or Out Resources

Reporting a Claim

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9/19/2017 2

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
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9/19/2017 3 Determining Compensability Most claims are compensable Compensable vs Non-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

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9/19/2017 4 Injured Worker Benefits

Income Benefits:

Temporary (TIBs) Impairment (IIBs) Supplemental (SIBs)

Monetary

Injured Worker Benefits

Other Benefits

Medical Death Burial

Dispute Resolution

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9/19/2017 5 Dispute Resolution

Administrative Process Judicial Review

  • Benefit review conference

(BRC)

  • Contested case hearing (CCH)
  • Appeals panel
  • Binding arbitration

Subrogation

Subrogation

Injury caused by a negligent third party

Employee sues responsible party Carrier pays workers’ comp benefits Carrier asserts lien or joins lawsuit Policyholder loss run benefits from success

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9/19/2017 6

Employer Best Practices

Employer Best Practices

Complete first report

  • f 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 and witnesses – Get written statements Contact OSHA File no later than 8th day after lost time begins

Within 8 hours for fatality of accident resulting in hospitalization of three or more workers

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9/19/2017 7 Medical Treatment

  • Arrange for prompt medical treatment
  • Network – visit texasmutual.com
  • 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

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9/19/2017 8 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 network participation Employer responsibilities Employee responsibilities Access to care

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9/19/2017 9

Policyholder Resources

Texasmutual.com Tools Texasmutual.com Tools

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9/19/2017 10

Questions?

Thank you!