29 Aug

Claims Uncovered: Part II

Posted at

4:03pm

in

In this interview, a continuation from last month’s article, Claims Uncovered Part 1, Ashley addresses common questions our clients have regarding claims reporting, processing, and unusual claims issues.

Q&A with Ashley Johnson, Claims Coordinator

What if a non-employee is at fault in a workers’ compensation claim? Will the liable party be handling the claim or will it still go through workers’ compensation insurance?

Our client company still needs to file a claim, even if the incident is someone else’s fault. The treatment of the claim goes through workers’ compensation insurance, and the claim will be reviewed for subrogation against the liable party in order to recover amounts paid on the claim. Subrogation is insurance jargon referring to the ability of the insurance carrier to take over some of the claimants’ rights of payment from a liable third party in order to recover amounts paid on a claim. For example, a claim with a liable party could be a motor vehicle claim where the other driver was at fault or any other type of claim caused by an outside party.

What if the claimant doesn’t want to pursue a workers’ compensation claim and wants to seek recovery through the third party claim?

The claim still needs to be filed, even if the employee maintains they want to pursue a claim against the liable party. We will need all of the claim forms in order to set up the claim, review, and keep it on file as a Report Only. Report Only means that a claim is kept on file and is not reported to the insurance carrier. In many cases, if the third party finds out the claim is work related, they will require the claimant to treat through workers’ compensation. In the event that the employee changes his/her mind and decides to pursue the workers’ compensation claim, we will have the information necessary to immediately start handling the claim.

Do clients have to report injuries they don’t think are work related?  

Any injury the employee states happened at work or is related to work must be reported. A non-work related injury that is not reported cannot be properly investigated and denied, which would result in unnecessary exposure for VenSure and our client. If the client feels the claim is not work related, clients should notify us when reporting the claim. There is a section on the Employer’s Report of Injury Form (within the Claim Reports Procedures Packet) for clients to write details as to why the client believes the claim is not work related. The claim will then need to be investigated for compensability. In addition, we will need all available information pertaining to the claim. If possible, the clinic where the claimant is sent for treatment should be notified of the questionability and reasons why, so the doctor is better prepared to address causation. Once enough information is gathered to support that the claim is not work related, the claim will be denied.

Where do we send an employee for treatment?

Employees should be sent to an occupational clinic or, if there’s not one in the area, to an urgent care. Only in EMERGENCY cases should clients send them to a hospital. For more details on where to send employees for treatment, please see Claims Uncovered Part 1.

What happens when an employee is sent to the clinic?

When an employee goes to the clinic, they should have a post-accident drug screen performed. This should be on the protocol at the clinic. However, if it is not yet set up in the protocol, the client will need to request the drug screen. The doctor will also diagnose and treat the employee for any injuries. Work status will be addressed, and the doctor will determine if the employee should be off of work, assigned to light duty, or is ok to put back on regular duty.

What happens after the employee goes to the doctor and is placed on light duty?

If an employee is placed on light duty status, then a light duty position needs to be provided. It doesn’t have to be a modification of their regular position; it can be a completely different position in the company. It can even be a made-up, temporary position with any reasonable tasks that are within the claimant’s restrictions. If our client company cannot find a light duty position that can accommodate the restrictions given by the doctor, your VenSure Claims Coordinator should be notified. We will then work with the client company to provide a light duty position through our Alternative Light Duty (ALD) program. For further information on the ALD program, please look for our upcoming article on this topic or email Gin Harper, Claims Liaison, at claims@vensure.com.

What happens if an employee is taken off of work?

An employee who is taken off of work by the accepted treating physician will be losing wages. Each state has a waiting period, a period of time where benefits are not due for wage loss. In most states, this waiting period is 3 to 7 days. If the employee goes past the state’s mandated waiting period, the employee is then eligible for benefits. To find out what your state’s mandated waiting period is, please contact your Claims Coordinator. You can also find these details on your state’s workers’ compensation website.

What if our employee has retained an attorney?

Our client company needs to notify us as soon as they become aware of an attorney or receives any paperwork from an attorney. VenSure will need copies of any forms  or notifications that were sent to the client.

Considering all this…

If a question or problem arises regarding workers’ compensation claims, please feel free to contact the Claims Department. We would love to work together to help our clients understand what to do in order to best impact each claim.


Ashley Johnson
, Claims Coordinator