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Checklist on Handling Workers Compensation Claims

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Checklist on Handling Workers Compensation Claims Powered By Docstoc
					This document provides a checklist of issues an employer should consider when
handling workers’ compensation claims. This form provides guidance and procedures
business should consider when a workplace injury occurs, including how to document
an employee’s claim. This document also provides issues an employer should consider
when trying to evaluate possible workers’’ compensation fraud. This document is useful
to any employer needing a checking to help analyze workers’ compensation issues.
Regarding the employee:

1. Name, nicknames, maiden name, previous names.
2. Current and previous addresses and the length of time living at said addresses.
3. Phone number, pager number, cellular number.
4. Social security and driver’s license numbers.
5. Sex.
6. Date of birth.
7. Marital status
8. Dependents and immediate family contact.
9. Date of hire.
10. Job classification.
11. Vehicle (type, year, license number).
12. Interests such as hobbies.
13. Length of time as a state resident.

Regarding the injury:

1. Time and date of injury.
2. Date of death (if applicable).
3. State of injury.
4. Nature of injury (sprain, fracture, etc.)
5. Body part(s) affected; any previous injury to the affected body part(s).
6. Source of injury (machines, hand tools, buildings, etc.)
7. Type of injury (fall, struck by object or vehicle, overexertion, repetitive motion
trauma).
8. Witnesses.
9. Work process involved (lifting, carrying, etc.)
10.To whom was the injury reported.
11. Who filled out the first report of injury report.
12. Plant or location.
13. Job.
14. Time and date the injury was reported.
15. Shift, if applicable.

Regarding the claim:

1. Date employer first notified.
                                                                                        ©
2. Who was notified, by whom?
3. Date employer was notified of workers’ compensation claim.                           C
4. Date insurance company or service company notified.                                  o
5. Date state agency notified.                                                          p
6. State case number.                                                                   y
                                                                                        r
7. Average weekly wage.                                                                 i
8. Benefit rate.                                                                        g
                                                                                        h
                                                                                        t

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9. Health care providers and costs.
10. Other benefits lost (Did the employer stop paying vacation, health benefits, etc.?)
11. Other benefits received.
12. Date disability started.
13. Date of first payment.
14. Projected return-to-work date.
15. Date case closed.
16. Date of maximum medical improvement.
17. Impairment rating.
18. Lost days.
19. Total benefits paid.
20. Vocational rehabilitation activity.
21. Subrogation (Is some third party responsible?)
22. Second injury fund potential.

The business owner should get an oral statement from the injured worker:

1.   Conduct the interview in a non-adversarial setting.
2.   Demonstrate concern and empathy.
3.   Allow the worker to talk.
4.   Do not rush the worker.
5.   Reenact the accident.
6.   Check for photos and/or video of the accident.

The business owner should get a written statement from injured worker:

1.   Note the location where the statement is taken.
2.   Let the employee write the statement, if possible.
3.   Statement is taken ASAP after the injury.
4.   Describe the worker’s pre-injury and post-injury actions.
5.   Request that the worker and any witnesses sign the statement.
6.   Make sure the employee initials any changes.
7.   Give copy of statement to employee.
8.   List the date and time of the statement.

The business owner should get oral statements from witnesses:

1.   Note witness’ location at the time of injury.
2.   Record witness’ relationship to the injured worker.
3.   Interview witnesses individually.
4.   Do not rush the witness.
5.   Make sure the statement is unrehearsed.

The business owner should get written statements from witnesses:

1. Make sure the witness writes the statement in ink.



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2. Record the stated ASAP after the injury.
3. Make sure the witness records his/her actions before, during and after the time of
injury.
4. Request that the witness sign the statement and initial any changes.
5. Record the date and time of the statement.
6. Give a copy of the statement to the witness.

If litigation occurs:

1.   Defense attorney, law firm.
2.   Claimant attorney, law firm.
3.   Identify judge.
4.   Costs of litigation (spending more than paying?)
5.   History of dispute.
6.   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:

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

About the workplace:

1. The injured worker’s workplace is experiencing labor difficulties
2. 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:



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1. The injured worker was not injured in the presence of witnesses
2. The injury is a subjective one, like stress, emotional trauma, or is hard to prove, like
back pain, headache, insomnia, etc.
3. The accident is not promptly reported by the employee to the employer
4. The employers’ first notice of the injury is from an attorney or a medical clinic, and
not from the injured worker
5. Physicians who have examined the injured worker have vastly differing opinions
regarding the injured worker’s disability
6. There is no sound medical basis for the disability; all physicians’ reports indicate a
full recovery
7. The injured worker is claiming disability exceeding that which is normally consistent
with such an injury
8. The accident occurs late Friday afternoon or shortly after the employee reported on
Monday
9. The claimant has the accident at an odd time, such as at lunch hour
10. The accident occurs in an area where the injured employee would not normally be
11. 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
12. The details of the accident are vague or contradictory

About the medical relationship:

1. The claimant frequently changes physicians or medical providers.
2. The claimant changes physicians when a release for work has been issued.
3. 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.
4. The employer’s first report of injury contrasts with the description of the accident set
forth in the medical history.
5. The injured worker develops a pattern of missing physician’s appointments.

About the claim itself or the claimant’s attorney:

1. The injured worker’s attorney requests that all checks and correspondence be sent
to the attorney’s office.
2. The claimant’s attorney is known for handling suspicious claims.
3. The attorney lien or representation letter is dated the day of the reported accident.
4. The same doctor/lawyer combination previously known to handle the same kind of
injury is handling this claim.
5. The claimant is unusually familiar with workers’ compensation claims procedures
and laws.
6. The claimant initially wants to settle with the insurer but later retains an attorney and
files increasingly subjective complaints.
7. The claimant’s attorney threatens further legal action unless a quick settlement is
made.



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8. There is a high number of applications from a specific firm.
9. The claimant’s attorney inquires about a settlement or buyout early in the life of the
claim.
10. 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:

1. There are tips from fellow employees, friends, or relatives suggesting that the injured
worker is either working or is active in sports.
2. The injured worker’s rehabilitation report shows evidence of other activity.
3. The injured worker is in a trade that would make it possible to otherwise work while
collecting compensation.
4. 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.
5. 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.
6. The injured worker leaves different daytime and evening telephone numbers.
7. The injured worker is never home when called or is always “sleeping and can’t be
disturbed” (especially during work hours).
8. Return calls to the claimant’s residence have strange or unexpected background
noises that indicate it may not be a residence.
9. The claimant has several other family members also receiving workers’
compensation benefits or other “social insurance” benefits, such as unemployment.




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DOCUMENT INFO
Description: This document provides a checklist of issues an employer should consider when handling workers’ compensation claims. This form provides guidance and procedures business should consider when a workplace injury occurs, including how to document an employee’s claim. This document also provides issues an employer should consider when trying to evaluate possible workers’’ compensation fraud. This document is useful to any employer needing a checking to help analyze workers’ compensation issues.