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Handling a Claim: Employer and Employee Responsibilities

Handling a Claim: Employer and Employee Responsibilities

Accidents happen. There are procedures to follow when an employee is injured at work. Business owners and employees have responsibilities they must fulfill for things to proceed. Although the specifics of the laws will vary from state to state, there are some general duties that apply nationwide. Below is a discussion of employer and employee responsibilities in workers' compensation claims.

Employer Responsibilities

Every state except Texas requires employers to carry workers' compensation insurance. Small business insurance policies are available for small companies. Businesses with even one employee must have some type of workers' compensation.

As an employer, you are responsible for avoiding workplace injuries by providing your employees with a safe place to work. After an employee injury, you must complete a First Report of Injury and forward it to your workers' compensation carrier.

You are responsible for ensuring you do not violate any laws or rights of the injured employee. If an injured employee needs medical attention for a serious injury, allow them to see the company doctor or leave work to see their own doctor.

Cooperate With Your Insurance Carrier

You are responsible for cooperating with your workers' compensation carrier, claims adjusters, and attorneys in investigating the matter. These parties will likely need your documentation of the injured employee's payroll history. They may request a copy of the injured employee's personnel file. They may ask to speak to the injured employee's supervisor or co-workers to confirm the injured worker's story. Provide them with timely assistance. It will help to be familiar with your insurance policy.

When an attorney for the employee contacts you, inform your workers' compensation carrier or their attorney. Do not provide documents to anyone else. Let your carrier and attorney take care of those requests, if appropriate. Treat this like any other business insurance claim, and let your legal team handle it.

Employee's Return to Work

You are responsible for welcoming an injured employee back into the workplace once they can return to work. You may not penalize or terminate an employee because they have filed a workers' compensation insurance claim. If you do, you may face serious civil or criminal charges.

Workers' Compensation Board

You are responsible for assisting your state workers' compensation board in curbing fraud. Most people know an employee can commit fraud by lying about an injury or exaggerating symptoms. However, employers can also commit workers' compensation fraud. For example, you cannot limit your First Reports of Injury in the hope that keeping your claims history down will reduce premiums. It will not take long for your injured employees to determine why they are not getting their benefits.

Employee Responsibilities

Employees have a duty to act responsibly while at work. Worker's compensation benefits will not apply in all situations. Some types of claims are specifically excluded from workers' comp. Covered injuries and illnesses include:

  • Medical expenses related to bodily injuries at work
  • Lost wages during treatment and recovery
  • Follow-up treatment

Injuries and illnesses that are not covered may include:

  • Injuries incurred due to intoxication or impairment
  • Injuries due to knowing violation of a policy or code
  • Horseplay or intentional misconduct

Workers ' compensation does not cover natural disasters (earthquakes, tornadoes, etc.), business interruptions due to civil disturbances, and product liability claims. Workers' comp only pays for injuries caused on the job or due to job conditions. Injuries or illnesses due to these or other causes may require separate legal action.

Report the Injury

You should immediately report your injury to your employer or immediate supervisor. Your employer must fill out a form, sometimes called a First Report of Injury, for every injury that occurs in the workplace. Make sure that your employer fills out a form for you. Review the form to make sure that it is accurate, and request that you receive a copy for your own records.

Don't delay in reporting a work injury. What may seem like a minor injury may only increase in seriousness if you fail to go to the doctor for treatment. You are also responsible for following your doctor's orders. The claims process is very strict. Obtaining benefits for your injury is difficult if an injury is not reported immediately.

For example, you injured your back in a fall at work. You went to see a chiropractor and didn't lose any time from work. Three years later, your back starts to hurt in the same place. You think the original fall caused it, but you may be unable to file a claim because workers' compensation claims have statutes of limitation, like other personal injury claims.

Be Cooperative

Cooperate with any requests by the insurance company. Avoid omissions. The insurance company may ask that you visit a physician for an independent medical examination (IME). You should agree to this examination. You have the right to see your own doctor, but the business owner's policy may require an IME for legal purposes. Keep all appointments set by the insurance company.

Be Responsible

Be responsible with information that you receive from your employer regarding your injury. Keep all insurance coverage documentation and medical records for informational purposes. You may need this information later.

Follow all doctor's instructions and advice. Communicate with your employer and the insurance company. When the doctor believes you can return to work, contact your employer or human resources to ensure your position is still open or that an equivalent position is available.

Be Cautious

Don't discuss your case on social media. Don't post pictures of yourself lounging around a swimming pool, even if they are old pictures of a past vacation. Insurance agents have taken these kinds of posts out of context to damage claim settlements in the past. Private investigators and agents monitor social media sites for scofflaws and frauds.

Do not return to business property until you're ready to return to work. Unless you have a reason for being there, you should not be on the property.

Other Types of Claims

Workers' compensation is not the only type of claim small business owners and employees may face. Workers' comp allows workers to have their medical bills paid while protecting the business owners from liability for the injury. If a worker's injury is due to other causes, or if the incident injured other parties, the employer may need additional types of insurance. Here are some types of insurance you should be aware of:

  • General liability insurance covers customers and visitors to the property. It also covers property damage caused by routine incidents. Most businesses have commercial general liability insurance.
  • Commercial auto insurance covers employees while driving company vehicles. This commercial property insurance protects you against claims made by other drivers' insurance providers after an accident.
  • Professional liability insurance, or professional malpractice insurance, may be needed depending on the type of business you operate. Medical and legal professionals typically have this insurance, but financial businesses should also carry it.

Filing a commercial insurance claim for the employer or employees is a critical part of business operations. To keep your financial losses and insurance premiums down, be sure you have the type of coverage you need before anything happens. File your claim right away, and prevent any further damage to the property.

Get Legal Help With Handling an Employment-Related Claim

Workers' compensation insurance is required in nearly every state. Protecting your workers helps protect your business income. For workers, workers' comp gets you back on your feet without having to pay deductibles and spend your own money. If you have concerns about your benefits, an employment law attorney can advise you on how to proceed in a workers' compensation case.

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