Checklists for Handling Workers’ Compensation Claims

Checklist for handling claims

The initial period is critical in handling workers’ compensation claims. Be sure to:

Immediately

•	administer first aid
•	accompany injured worker to a selected medical provider
•	report incident within company
•	notify family
•	assign responsible person to follow claim

First day

•	report to claim handler outside company (insurance company or third-party administrator)
•	determine, on a preliminary basis, whether the injury is covered by workers’ compensation
•	counsel employee and/or family on claims procedures, available benefits, company’s continuing interest in employee’s welfare, etc.
•	follow up with the employee or family

First week

•	coordinate payment of initial benefits
•	talk to treating physician to learn diagnosis and treatment plan
•	evaluate whether medical rehabilitation is necessary or appropriate
•	develop return-to-work plan
•	forward mail
•	contact the injured employee and/or the family

First month

•	use a “wellness” approach (cards, phone calls, visits) to continue to reinforce company’s concern
•	consider medical examination by independent physician, if warranted
•	reevaluate treatment plan based on new medical information
•	update return-to-work plan
•	contact the injured employee and/or the family

Ongoing

•	continually reevaluate treatment plan
•	update return-to-work plan
•	refer for vocational rehabilitation
•	refer for pain management evaluation of chronic pain, if appropriate
•	maintain contact with the injured employee and/or the family

Checklist for collecting information

Whether it’s the businesses owner, or someone assigned by the business owner to keep track of the claim, here’s some advice for the types of information the person overseeing the claim should be gathering:

About the employee

•	name, nicknames, maiden name, previous names
•	address—current and previous (length of time living at both addresses)
•	phone number, pager number, cellular number
•	social security and driver’s license numbers
•	sex
•	date of birth
•	marital status
•	dependents and immediate family contact
•	non-relative contact
•	date of hire (state hired, if applicable)
•	job classification, if applicable (insurance class or company classification)
•	vehicle (type, year, license number)
•	interests—hobbies
•	length of time as a state resident

About the injury

•	time and date of injury
•	date of death (if applicable)
•	state of injury
•	nature of injury (sprain, fracture, etc.)
•	body part(s) affected; any previous injury to the affected body part(s)
•	source of injury (machines, hand tools, buildings, etc.)
•	type of injury (fall, struck by object or vehicle, overexertion, repetitive motion trauma)
•	witnesses
•	work process involved (lifting, carrying, etc.)
•	to whom was the injury reported
•	who filled out the first report of injury report
•	plant or location
•	job
•	time and date the injury was reported
•	shift, if applicable

About the claim

•	date employer first notified
•	who was notified, by whom?
•	date employer was notified of workers’ compensation claim
•	date insurance company or service company notified
•	date state agency notified
•	state case number
•	average weekly wage
•	benefit rate
•	health care providers
•	health care costs
•	other benefits lost (Did the employer stop paying vacation, health benefits, etc.?)
•	other benefits received
•	offset for other benefits
•	date disability started
•	date of first payment
•	projected return-to-work date
•	date case closed
•	date of maximum medical improvement
•	impairment rating
•	lost days
•	total benefits paid
•	reserves
•	vocational rehabilitation activity
•	subrogation (Is some third party responsible?)
•	second injury fund potential

Oral statement from injured worker

•	conduct the interview in a nonadversarial setting
•	demonstrate concern and empathy
•	allow the worker to talk
•	do not rush the worker
•	reenact the accident
•	check for photos and/or video of the accident

Written statement from injured worker

•	note the location where the statement is taken
•	let the employee write the statement, if possible
•	statement should be written in ink
•	statement is taken ASAP after the injury
•	describe the worker’ preinjury and postinjury actions
•	request that the worker and any witnesses sign the statement
•	make sure the employee initials any changes
•	give copy of statement to employee
•	list the date and time of the statement

Oral statement from witness(es)

•	note witness’ location at the time of injury
•	record witness’ relationship to the injured worker
•	interview witnesses individually
•	do not rush the witness
•	make sure the statement is unrehearsed

Written statement from witness(es)

•	make sure the witness writes the statement in ink
•	record the stated ASAP after the injury
•	make sure the witness records his/her actions before, during and after the time of injury
•	request that the witness sign the statement and initial any changes
•	record the date and time of the statement
•	give a copy of the statement to the witness

If litigation occurs

•	defense attorney, law firm
•	claimant attorney, law firm
•	judge
•	costs of litigation (spending more than paying?)
•	history of dispute
•	settlement

Warning Signals of Workers’ Compensation Fraud

You may not discriminate against a worker who has filed previous workers’ compensation claims.  However, when you have several of the following suspect behaviors present or you observe an emerging pattern, don’t be afraid to investigate further for possible fraud or to forward your suspicions to the appropriate authority.

About the worker

•	the injured worker has an unstable work history; i.e., an employee who often changes jobs
•	the claimant has a history of reporting subjective injuries which may include workers’ compensation or liability claims
•	the claimant is consistently uncooperative
•	the injured worker has been recently terminated, demoted, or passed over for a promotion
•	the injured worker is in line for early retirement
•	the injured worker is making excessive demands
•	the injured worker calls soon after the injury and presses for a quick settlement of the case
•	the injured worker moves out of state soon after the injury
•	the injured worker changes his or her address to a post office box or receives mail via a friend or relative

About the workplace

•	the injured worker’s workplace is experiencing labor difficulties
•	the accident occurs just prior to job termination, layoff, after formal discipline of the employee, or near the end of the employee’s probationary period

About the injury

•	the injured worker was not injured in the presence of witnesses
•	the injury is a subjective one, like stress, emotional trauma, or is hard to prove, like back pain, headache, insomnia, etc.
•	the accident is not promptly reported by the employee to the employer
•	the employers’ first notice of the injury is from an attorney or a medical clinic, and not from the injured worker
•	physicians who have examined the injured worker have vastly differing opinions regarding the injured worker’s disability
•	there is no sound medical basis for the disability; all physicians’ reports indicate a full recovery
•	the injured worker is claiming disability exceeding that which is normally consistent with such an injury
•	the accident occurs late Friday afternoon or shortly after the employee reports to work on Monday
•	the claimant has the accident at an odd time, such as at lunch hour
•	the accident occurs in an area where the injured employee would not normally be
•	the task that caused the accident is not the type that the employee should be involved in; i.e., an office worker who is lifting heavy objects on a loading dock
•	the details of the accident are vague or contradictory

About the medical relationship

•	the claimant frequently changes physicians or medical providers
•	the claimant changes physicians when a release for work has been issued
•	a review of medical reports provides information that is inconsistent with the appearance or behavior of an injured person; i.e., a rehabilitation report describes the claimant as being muscular, with callused hands and grease under the fingernails
•	the employer’s first report of injury contrasts with the description of the accident set forth in the medical history
•	the injured worker develops a pattern of missing physician’s appointments

About the claim itself or the claimant’s attorney

•	the injured worker’s attorney requests that all checks and correspondence be sent to the attorney’s office
•	the claimant’s attorney is known for handling suspicious claims
•	the attorney lien or representation letter is dated the day of the reported accident
•	the same doctor/lawyer combination previously known to handle the same kind of injury is handling this claim
•	the claimant is unusually familiar with workers’ compensation claims-handling procedures and laws
•	the claimant’s attorney complains to the carrier’s CEO at the home office to press for payment
•	the claimant initially wants to settle with the insurer but later retains an attorney and files increasingly subjective complaints
•	the claimant’s attorney threatens further legal action unless a quick settlement is made
•	there is a high number of applications from a specific firm
•	the claimant’s attorney inquires about a settlement or buyout early in the life of the claim
•	the claimant writes unsolicited statements about how much better he/she is, but treatment continues and the claimant doesn’t return to work

About outside activities

•	there are tips from fellow employees, friends, or relatives suggesting that the injured worker is either working or is active in sports
•	the injured worker’s rehabilitation report shows evidence of other activity
•	the injured worker is in a trade that would make it possible to otherwise work while collecting compensation
•	the injured worker is exaggerating an injury in order to get time off to work on personal interests; i.e., the injured worker is remodeling or building a home concurrently with the injury 
•	the injured worker is in a seasonal business that would make it attractive to be “injured” during the off-season; i.e., occupations in fields such as roofing, landscaping, plumbing, farming, masonry, etc.
•	the injured worker leaves different daytime and evening telephone numbers
•	the injured worker is never home when called or is always “sleeping and can’t be disturbed” (especially during work hours)
•	return calls to the claimant’s residence have strange or unexpected background noises that indicate it may not be a residence
•	the claimant has several other family members also receiving workers’ compensation benefits or other “social insurance” benefits, such as unemployment