By: Tony Matera / @WI_InsSolutions

 

In the last couple of weeks we have taken a look at the basics of Workers Compensation (Work Comp), the importance of timely claims reporting, and how to prepare for your year end audit. This has all been part of our series giving insight to the often misunderstood and complex coverage facing most business owners. This week I reference the Wisconsin Department of Workforce Development's (DWD) suggestions on how employers can protect themselves from fraudulent claims. I will also show what employees can do if they feel that a claim should have been covered.

The question often comes up as to whether an injury or ailment is compensable as a Work Comp claim or personal injury. I can share a personal story from when I injured my knee playing soccer. On every trip to my doctor or physical therapist, I was asked if this was a work related injury. Why? Because the hospitals get paid quickly and often times higher rates when it is an insurance company paying rather than an individual. That’s why a lot of doctors will ask leading questions during an initial exam to steer the conversation toward a Work Comp discussion.

So, what can you do if you as an employer suspect that an employee is not injured or that the injury was not work related? Here are 10 steps the Wisconsin Department of Workforce Development has to protect you:

Following are some basic elements of a good accident response program. These “tips” came from the suggestions of experienced worker’s compensation claims personnel and defense attorneys. By following these suggestions you should be able to not only reduce exaggerated or abusive claims, you should also bring down costs from true workplace injuries.

1. Policy Statement

Develop a clear and strong policy statement on the importance of promptly reporting all suspected accidents and injuries to supervisors or designated worker’s compensation claims representatives. Make it clear that filing false claims is grounds for discharge. Put the statement in work rules and procedure manuals. Make sure all employees know and understand the policy and rules.

2. Knowledgeable Managers

Make sure that all supervisors know how to handle worker’s compensation claims, including:

 

• who to send the worker to for completing the report of injury

 

• the importance of immediate investigation of the circumstances surrounding the  injury including witness reports
• Poor communication between the employer and the insurer is very often at the root of inappropriate payment of marginal or invalid claims. Train your claims reporting personnel on how to thoroughly document a reported injury. Unfortunately, filling out forms tends to be regarded as menial or undesirable work. As a result, inexperienced people fill them out.  Have an experienced person fill in the form and make sure the facts stated in it are accurate.

3. Obtain Accurate Information

Ask for a statement about the nature of the accident and the injury suffered from the claimant. Let them record the cause and nature of the accident in their own words. Encourage them to be specific. They should sign and date the statement.

4. Establish Preventive Practices

Reenact accidents--even minor ones-- to determine what happened and how the hazard can be avoided in the future. The emphasis of this reenactment should be safety and injury prevention; gathering useful evidence of abuse is just a by-product. If possible, include union representative, safety manager, supervisor, injured worker, and other interested parties. The more visible and “team oriented” the effort, the better.

5. Prompt Reporting

Promptly report the claim to your carrier along with any suspicious circumstances that may require further investigation.  Late reporting of claims increases lost time and medical cost, fosters abusive claims, and increases the probability of expensive litigation.

6. Obtain Medical Attention

Have the supervisor accompany the injured worker to the provider for emergency or, with the employee’s permission, to initial non-emergency treatment. The supervisor should observe the quality of treatment and report any problems to the company, e.g., long delays, rude treatment, or doctors that seem to be “out of touch” with occupational injuries. Getting the injured worker to high quality doctors that are savvy to occupational medicine is one of your best means of avoiding exaggerated claims. The supervisor should try to talk to the provider about the nature of the injury and options for early return to work.

7. Return to Work Options

The employer should periodically check with the medical provider to discuss return to work options.

8. Value the Employee

Stay in touch with your injured employee. Encourage them to stay faithful to prescribed therapy.  Encourage employees to keep medical appointments and to be available when you call.

9. Maintain Safe Work Place

Make the main purpose of your safety program the prevention of injuries to your workers by the removal of hazards, proper training and the enforcement of safe work habits. Make this intention clear to your workforce.

 

From the Wisconsin Department of Workforce Development website, http://dwd.wisconsin.gov/wc/insurance/fraud/ten_helpful_hints.htm).

Sometimes a claim IS denied that the employee feels was legitimate. The system is set up to hear both sides. Premium amounts are directly affected when injured workers file for benefits.

Reasons for Denial of a Claim

If your employer or its insurance company denies your clam, or any part of it, it should inform you in writing. Typical reasons given for denying a claim are:

• You didn't suffer a serious injury.

• Your injury didn't take place during work, or within the scope of employment.

• You don't need medical treatment for your injury.

• You don't need time off work for your injury.

Fighting a Denial of Benefits

The bottom line is this: employees who have become injured or sick as a result of their job should file for workers' comp to protect themselves, and if their claim is legitimate and has been denied, they should fight the insurance company, with the help of a lawyer. Whether or not the employer believes that the worker is legitimately injured will turn out to be irrelevant, and the worker shouldn't worry about whether the employer holds the employee in contempt for filing a claim. It is the worker's right to have time off work and medical treatment paid for; the worker has given up the right to sue the employer in exchange for the workers' comp benefits and should not feel guilty about using them.

Wisconsin Department of Workforce Development website (http://dwd.wisconsin.gov/wc/workers/) has very good information that the injured employee can reference including:

• Am I Covered?

• When Does Coverage Begin?

• What Benefits are Included?

• How Do I File a Worker's Compensation Claim?

• Flow of a Claim

• How Can I Return to Work?

• Vocational Rehabilitation Information

• What Happens If My Claim is Denied?

• What Happens at a Hearing?

• What Do I Do If My Employer does Not have Insurance?

• When is My Employer Required to Have Worker's Compensation Insurance?

• Does My Employer Have a Worker's Compensation Insurance Policy? and What is the main Claim(s) Handling Address (PDF)?

• Injured Worker's Rights and Responsibilities

From the Wisconsin Department of Workforce Development website, http://dwd.wisconsin.gov/wc/insurance/fraud/ten_helpful_hints.htm).

I hope this week’s look at both sides of disputing a work comp claim has helped. As always if you want more information or have questions please feel free to contact me directly. Thanks for checking in.

Be Safe!

 

Tony Matera is a licensed independent insurance advisor with Ansay and Associates out of Port Washington WI. And is the Servicing Agent for ONMILWAUKEE.COM For more information contact him at tony.matera@pw.ansay.com or call directly at 262-376-3248 www.linkedin.com/in/TONYMATERA