Workers’ Compensation Claim Process Guide

What is the workers’ compensation claim process?

The workers’ compensation claim process is a series of steps employees must take to receive insurance benefits after a work-related illness or injury. It involves reporting incidents to the appropriate person, often an internal HR department member, who will work closely with the employee to complete their claim. 

Typically, employers are involved closely in the workers’ compensation claim process to ensure that their HR team or outsourced HR provider processes claims correctly and maintains regular communication with the filing employee and the business insurance provider. Employers should also be actively involved in planning the employee’s return to work after recovery.

Dennis Shirshikov, adjunct professor of economics at City College of New York, emphasized the importance of a simple, easy-to-follow workers’ compensation claims process. “Have a clear reporting system, rapid medical access and a direct line of contact with the insurer,” Shirshikov advised.

The workers’ compensation claim process for employers

Adhering to the workers’ compensation claim process will help you comply with your state’s requirements and provide appropriate support to your employees. While your state may have specific provisions, the following steps generally will apply.

1. Your HR team tends to the employee’s immediate needs.

Injured or ill employees are often unable to file claims immediately after an incident. Instead, the primary focus should be on caring for the employee.

Your HR staff — if present at or near the site of an injury — should administer first aid. If necessary, your HR team should arrange for medical care by sending the employee to a doctor or hospital and contacting the employee’s emergency contact. “Many employers may approve rapid medical care before the legal paperwork is completed,” Shirshikov noted.

2. You or the employee begin working on a formal claim.

After the employee’s immediate needs are met, they should file a written report within 24 to 48 hours of the incident. At that point, you’ll file a formal claim with your business insurance provider.

To begin filing the insurance claim, you and the employee should meet with your HR team. During this meeting, all parties should discuss who will complete the required injury or illness report. Sometimes, the employee will complete it alone; other times, you’ll handle it with their assistance. Your HR team can answer questions as needed.

Key information that typically must be provided includes the following:

• Incident date and location
• Injury or illness description
• The date the employer learned of the incident
• The date you gave your employee their claims paperwork
• The date you received the employee’s completed paperwork

Depending on your state, you may also need to file state workers’ comp board forms.

3. You explain the workers’ comp process to your employee.

Chris Peterie, CEO and co-founder of Tower Street Insurance, emphasized the importance of clear communication with the affected employee. “Clear communication is key,” Peterie advised. “Educate employees about the process, provide accessible forms and designate a point person to guide them through the steps.”

Before filing a claim, walk the employee through the workers’ comp process so they know what to expect. Ensure you cover the following points:

• Report filing timeline: Ideally, the employee will file a claim within 24 to 48 hours of an incident. However, this goal may sometimes be unrealistic. That’s why the employee should know how long they have, under state law, to file claims. You should emphasize that claims filed outside this time frame could lead to a loss of benefits. Check your state’s guidelines to determine its report filing deadlines.
• Healthcare options: In some states, employers can designate specific doctors employees must see for work-related illnesses and injuries. Regardless of state-specific provisions, your HR team should thoroughly explain the employee’s healthcare options.
• Additional healthcare considerations: Employees should be advised to retain all paperwork from their doctor visits. Additionally, although healthcare facilities usually file claims directly with your workers’ compensation provider, you should still give your employee the provider’s contact information. Lastly, ensure employees know whether their travel costs to and from healthcare appointments are reimbursable.
• Wages: If an injury or illness prevents an employee from working, discuss how their wages will be replaced during their leave. Requirements vary by state and may include a maximum leave wage amount.
• Time-off usage: Employees should understand how your company’s time-off policies do and don’t intersect with your workers’ comp plan, relevant state laws and the federal Family and Medical Leave Act (FMLA). Discuss whether days employees spend on workers’ comp leave also count as vacation days, paid time off or any similar company policies.

4. You file a formal claim.

With the previous steps complete, you can now file a formal workers’ comp claim with your insurance provider. Even if your employee completes the claims paperwork on their own, you and your HR team should file the claim on the employee’s behalf.

Before filing the claim, ask your insurance provider how it prefers to receive claims. Electronic submission works for some, while others prefer postal mail or telephone claims. You should ask your provider whether you must also file the claim with your state’s workers’ comp body. In some cases, your provider will handle this step for you. 

“Ensuring claims approval requires accuracy, promptness and thorough documentation,” Peterie noted. “Open communication with your insurance provider is essential, as it thoroughly investigates and documents the incident to prevent disputes or delays.”

5. You maintain contact with all parties.

Once your claim is filed, maintain regular contact with your insurance provider and your employee. This way, you can complete or forward any additional documents.

Your HR staff should also update your employee on the status of their claim regularly and remind the employee when they should expect to hear from the insurance provider about medical concerns and wage replacement.

6. Your employee receives the insurer’s decision.

While the above steps are essential, they don’t guarantee claim approval. Ultimately,

your insurance provider decides whether to approve the claim based on whether the information provided fits your plan’s terms.

If your provider approves your claim, your employee has two options. They can either accept the benefits offered, which typically include coverage for medical costs and lost wages or negotiate for more money. Similarly, in the case of a denied claim, the employee can demand a review or approval.

7. The employee returns to work.

After your employee has tended to the injury or illness covered in their claim, they should return to work. Before doing so, they should notify you and your insurance provider of their intended return date.

As your employee prepares to return to work, you should develop a customized program to facilitate their return. In doing so, consider the employee’s doctor-ordered medical restrictions on work duties and how these restrictions might affect their performance.

If necessary, create a temporary position for the employee until they can work at full capacity. Alternatively, if you have a current job opening that fits the employee’s restrictions better, you can assign them to this role until they are ready to return to their former position.

In some cases, your employee will be unable to return to work for an extended period, potentially meaning wage losses greater than their workers’ comp payout can cover. If so, you can try to extend the employee’s leave through FMLA, the Americans with Disabilities Act or company policy provisions.

How to make the workers’ compensation claim process easy

The best time to begin thinking about workers’ compensation is before an injury or illness occurs. It’s crucial to educate your team on workers’ compensation, what it entails and how to file claims. 

Consider implementing the following measures:

• Be prepared for injuries: Have a clear, documented plan in place and educate employees on what to do if someone gets hurt on the job. Train managers and supervisors on proper injury reporting procedures, including how to document incidents accurately and support injured or unwell employees.
• Review coverage with your insurance carrier: Know what is and isn’t covered so you can accurately advise employees on their workers’ comp benefits.
• Create a direct link between employees and insurance companies: Ensure injured employees can easily contact the insurance company to give statements and provide documentation of their injuries and medical care.
• Designate a workers’ comp coordinator: Assign a point person in HR who is trained in workers’ comp policies and can assist employees throughout the claims process.
• Provide step-by-step claim guides: Create easy-to-follow guides that outline each step of the claims process and make them available in employee handbooks.
• Set up a digitized claims process: If possible, use online claims filing systems or HR software that allows employees to submit claims electronically, track claim status and access necessary documents.

Kimberlee Leonard contributed to this article.