Workers’ Compensation was designed to assist your injured employee with the process of recovery from a work related injury. As your insurance carrier, our partnership with you in this process is to investigate and validate the legitimacy of all claims, actively pursue recovery from any potential third parties who may have been responsible for causing the injury, provide proper benefits to the employee and see to it that s/he receives the most timely and appropriate medical care available so s/he can return to a normal lifestyle of gainful employment with as minimal interruption to your business operations as possible. As an employer, your partnership role in this recovery process is equally important by keeping in constant communication with us and the employee.
Report a Claim
Our claims approach provides prompt investigation, evaluation and conclusion of the claim.
It is essential that you notify us of any claim or other loss as soon as possible, since nothing can be accomplished until this step is taken. It also gives us the opportunity to investigate while:
- Memories are fresh.
- Witnesses are more likely to be available.
- Physical surroundings are unchanged.
- Expert assistance can be used to help determine the cause.
- Control over the claim and its costs can be exercised.
- Property can be protected and preserved.
Prompt notice is also a practical necessity to minimize any potential disruption to the wages an employee may be losing while away from work. Contrarily, a delayed notice of an accident may also make investigation, adjustment or defense of the claim extremely difficult and costly. Fast, accurate claim reporting is in the best interest of all parties.
The Claims Process
Upon receiving your WC-1 report, we will contact you before the end of the next business day to verify and gather more detailed information.
If you do not receive a call from us, please contact:
As part of our prompt, thorough investigation, we will secure detailed information from you, the medical provider(s) and in most cases, the employee. During the fact finding stage of the investigation, we will be looking to you to provide valuable insight regarding the circumstances surrounding the incident to assist us with our determination on the best course of action to proceed. In some cases, we may not have enough information from one or more sources, whether it is medically or otherwise, to make a final determination. Accordingly, we may categorize the claim as “Denied Pending Investigation” in order to secure the necessary information to arrive at the most accurate conclusions. Once a final determination is made to accept or deny a claim, the parties are notified.
In the event an accident may have been caused by or attributed to a person or thing other than the injured employee, our investigation will include an exploration and determination regarding the feasibility, to pursue civil litigation or other actions of recovery against such third party. Although a recovery from a third party will not have any impact on the workers’ compensation benefits already owed to the injured employee, it will likely impact your insurance policy favorably. As such, during our investigation and determination process, we will require your assistance in order to achieve the maximum possible recovery.
An ideal way to keep workers’ compensation costs to a minimum is, of course, not to have any injuries. From a practical standpoint, however, this may not always be the case. Notwithstanding, the steps you take BEFORE and AFTER an injury can be decisive factors in determining the impact of workers’ compensation costs on your business operations and bottom line profitability.
BEFORE an accident occurs, you have a multitude of powerful, effective and proven tools, techniques and programs which you can implement to significantly limit or even avoid experiencing workplace injuries.
A few of these are:
- Safety programs
- In-service training for managers and employees
- Safety Committees
- Detailed ergonomic job analysis
- RTW (Return To Work) Program
- Employee incentive programs
- Management accountability programs
AFTER an accident occurs, how and how quickly you handle the situation can leave a lasting impression on that particular injury as well as curbing the potential for future injuries.
A few of the more significant actions include:
- Report the injury to Crum & Forster immediately.
- Investigate the “root cause” of an injury; how and why did this injury occur. Then, document your findings.
- Determine whether the accident could have been avoided and implement steps to prevent similar occurrences.
- Assess accountability; who may have been directly and indirectly responsible for ensuring the safety of the work environment. Accordingly, implementing appropriate corrective actions are often significant motivators for avoiding similar accidents.
- Exercise the role of the Safety Committee and the RTW Program.
We make every effort to ensure your employee is receiving the best, most appropriate and cost effective medical care available. In order to accomplish this, we continuously monitor the employee’s medical progress. At times, we may also include the services of a nurse case manager, who is a Registered Nurse (R.N.), to assist us with achieving this goal. We utilize nurses both in-house, as well as in the field depending on the specific needs of each situation.
The Workers’ Compensation Medical Fee Schedule, which is governed by the statutory rules and regulations, limit the amount of fees and costs which a medical provider may charge for rendering medical care, services and supplies to injured employees. However, not all medical providers consistently adhere to this billing regimen due to occasional system & data entry errors, accidental miscoding of medical procedures, duplicate & unrelated billing, and a number of other reasons. As such, we have partnered with medical bill review companies to ensure statutory compliance. Throughout the duration of a claim, medical bills are channeled through this process to verify that the medical costs paid on your claims are nothing in excess of what is reasonable and appropriate.
One of the tenets of workers’ compensation is to return the employee to work (RTW). To initiate this RTW process, we will ask that you complete a job description form which details the physical requirements of the employee’s regular work duties, as well as any available transitional work or modified/light duties. Upon receiving this completed form from you, the claims adjuster and/or nurse case manager will coordinate the RTW in tandem with you and the physician to return the employee to work at the most opportune moment when medically indicated. Once the employee has returned to work, medical treatments may continue until his/her condition has fully stabilized.
Having transitional work available is often a win-win situation for you and the employee. Some of the benefits include:
- Employees will tend to have a quicker return to full duty work.
- Having a productive employee assisting in another needed area of your operation.
- Significant savings in workers’ compensation costs.
- Ability to interact socially and professionally with co-workers.
- Ability to stay active and be productive.
- Ability to return to the work site at lesser wages or hours but still earn full wages (part paid by employer, part paid by insurance carrier).
- Ability to further focus on abilities vs. disabilities.
Alternate work options come in a variety of forms. Each has its own unique effectiveness, depending on the type of physical capabilities the employee may have at a given time.
Welcoming the injured employee back to his/her normal position, but with restrictions assigned by a physician.
Example: A physician declares that the injured worker has a 10 pound lifting restriction. It is important to emphasize to everyone including the injured worker, their supervisor and others that compliance with these restrictions is mandatory.
Having an existing position or creating a new position specifically for this employee, on a temporary or permanent basis, that is physically less demanding than their normal position and meets the physical restrictions set by a physician.
Example: A delivery driver accustomed to carrying and moving boxes up to 80 pounds is temporarily assisting the office with filling invoices, due to his 5 pound lifting restriction.
Bringing the employee back to their full working capacity over a set period of time. This process may begin with 1 or 2 hours of work a day and/or 1 or 2 days a week and gradually increases as time passes.
It is not uncommon for Transitional Duty to be combined with Light or Modified Duty.
Example: A new temporary position is created specifically for this employee to sit by the door and greet customers 1 hour/day at minimum wage.
Although some companies may not be able to have or create light, modified or transitional work due to the nature of their business, size of their existing workforce, economic conditions etc., every effort should be made to explore the feasibility for creating such work for the extensive social, emotional, and financial gains from which both you and the employee will reap.
PPD occurs when an employee has sustained permanent impairment as a result of the work injury. It is primarily determined by a medical exam from an objective independent physician in accordance with set impairment rating guidelines established by the American Medical Association. Although many cases do not result in any PPD, there are some that do. For these, an employee is entitled to additional benefits. The benefit amount corresponding to the impairment rating is clearly documented in statute and regulated by the Department of Labor.
If an injury results in noticeable permanent disfigurement, the employee may be entitled to a disfigurement award. Disfigurement includes scars, deformity, and discoloration. Laceration scars and surgical scars are reviewed six months from the date of the occurrence. Burn scars are evaluated after one year.
Upon conclusion of a workers’ compensation claim, we will file a WC-3 Final Carrier’s Case Report with the Department of Labor, a copy of which will be provided to the injured employee and your insurance agent. This report will outline all the payments made to the employee, medical providers and other parties involved with the case. A similar report is sent to you at the end of each year for all open claims. You may file these reports in your records, as appropriate.
Should you have any questions regarding workers’ compensation, the claims process, or a particular claim, please visit our “FAQs” (Frequently Asked Questions) section which may help answer some of your questions. Otherwise, do not hesitate to contact your claims adjuster at 537-5221 or see the “Employer Contact Information” section for additional options
Workers’ Compensation can involve a number of benefits in addition to wage loss. Often times, after an employee has returned to work, the physician will continue to monitor the employee’s medical progress until treatment is no longer required. Unless a condition is more severe and will result in permanent disability, typically a case will then be reviewed for closure.
No, by law you are not required to offer light / modified / transitional duty. However, there are a number of benefits to making such work available. See “Light/Modified/Transitional Duty”.
The answer to this depends on the situation and circumstances. Since this issue involves an employment matter and is generally outside the scope of workers’ compensation, we recommend that you consult with your labor counsel or similar resource.
No. If the transitional work dictates a lower wage rate, workers’ compensation will cover the appropriate difference in pay. Although it is financially more beneficial to you to pay at the same wage rate, paying a lesser rate is still more advantageous than not having transitional work available at all.
Please forward it to us and keep a copy in your files. If we have not already received this information, we will use it to address the employee’s disability status.
TTD is based on 2/3 (66.67%) of the employee’s average weekly wages subject to a maximum amount.
Ask the employee to send the medication receipts to his/her adjuster with a request for reimbursement. We will determine if the request is appropriate and issue a reimbursement accordingly.
Reserves are established on a case-by-case basis on the extent of the case issues and the corresponding realistic financial outcome. The amount of the reserve is monitored and adjusted continuously to ensure accuracy.
That depends. According to state law, guidelines are in place which dictate the maximum recoverable amount which the employer can receive depending on the situation. For example, if an employee retains an attorney, and we do not, that attorney will typically take a portion of the employee’s recovery. Likewise, they will take a portion of the employer’s recovery as well.
Your best resource for this information is the claim adjuster who is handling that case. You may contact him/her at 808-537-5221. For additional contact options, see Employer Contact Information.