4 Major Hurdles in the Way of Workers’ Comp Claim Processing

by | Published on Jun 17, 2019 | Workers Compensation

Workers’ compensation protects employees who are injured on the job or become ill in a work-related incident. When a workers’ compensation claim is made, many formal processes are triggered into action among which medical records analysis and medical case chronology are significant ones. These processes help determine the nature and extent of the injury or illness. The injured worker is compensated for lost income and medical expenses if he/she is found eligible for the benefits. The claims application process needn’t be always smooth because there are specific laws and regulations involved. In this blog we look at some major problems workers face when filing a claim.

  • Not filing the claim on time: If you don’t file the claim within the stipulated time, the injury is not covered. An injured worker has 30 days to make a claim. However, it is best that the employer is informed regarding the injury or illness as soon as possible. It is not enough to notify the employer verbally; they have to be notified in writing as well. The claim form should be filled out correctly with the date, time, and details regarding the injury. Employees must maintain copies of all documents that are passed between them, the employer, and the insurer. This is useful in case the worker needs to obtain legal representation.
  • Facing reprisal for filing the claim: Though most states do not allow retaliation on the part of employers when a worker files a claim, it could happen. Employers experience increased premiums when there are claims in their organization, and therefore may get upset. Retaliation may be in the form of the employee being denied a promotion; getting lower pay or being scheduled for fewer hours; being demoted; having their working schedule changed to a less favourable one; harassment or extra scrutiny on the part of the supervisor; having to face uncalled for disciplinary action; or even getting fired. Since such reprisal could be difficult to prove, workers should keep notes of each detail.
  • Lack of clarity regarding physician visits and treatments: Workers are often unaware that they can only go to specific doctors during a workers’ compensation claim. Typically, they can choose someone from a panel of physicians approved by the insurer. If they choose to go to their personal doctor who may not be on the panel, their medical costs will not be covered.

Employees should take care not to exaggerate their injuries because if they are caught, their claim will be denied. They should ensure that they closely follow the treatment plan and go for all appointments. It is vital to get copies of all medical records for all visits.

  • Denied claims: This is the most serious problem employees may face. If the claim is denied, they will have to meet the treatment and rehabilitation costs on their own or use their health insurance to cover it. Moreover, they may find themselves out of work because of the injury and could even lose the job. Claims may be denied for reasons such as late filing, injury found to be not work-related, company denying it’s at fault, company claiming that the employee is a contract worker, or allegation that the employee is faking the injury.

Workers’ compensation attorneys and companies providing them with medical records services take great care to ensure that an injured worker receives due compensation by extracting and presenting crucial medical evidence from the medical records retrieved for the purpose. Even so, the claims processing can be intimidating especially when the employer or insurer is focused on denying the claim and thereby reducing costs. Keeping the possible hurdles in mind will help injured workers to be wary of the issues that could crop up along the way and try to avoid them successfully.

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