Common Troubles with Workers Compensation Claims Management

Common Troubles with Workers Compensation Claims Management

Have you ever experienced problems with a workers compensation claim?

It could be that “the claim was taking so long to settle?” Or “you were not been kept up to date on the claims progress?” Or “an injured worker doesn’t want to return to work when fit to do so?” Or “You can’t get anyone on the phone, and eventually you find out your file has been allotted to a new case manager.”

With workers compensation claims, when a worker is injured and the claim is lodged, the majority of the claims process takes place behind the scenes.

It can cause a lot of frustration, confusion and sometimes anger when employers lose control of the claim, and numerous troubles and complications can arise for both employers and the employees.

For employers:

Delayed claims reporting – Some employers may attempt to postpone reporting a workers injury and it happens a lot. This can interfere with insurers and their ability to successfully investigate claims. 

Invalid claims – Such claims happen on a daily basis and it should come as no surprise. It could be that workers do not have enough evidence to prove that their injury or illness was work-related.

Failure to oversee claims – Regrettably, many employers have a tendency to take a hands-off approach to workers’ compensation claims.

Once a claim is accepted, the employer plays a key role and has responsibilities to ensure that a workplace is safe for their employees, and to support the claims and rehabilitation process when an employee is injured while at work.

Failure to provide “return to work” programs for injured workers – Return to work (RTW) programs help manage costs by providing light-duty positions for workers, getting them back on the job as soon as possible. These programs work to keep employees involved and to reduce overall claims costs. Employers must establish clear-cut protocols when it comes to submitting injury claims, including the monitoring and periodic review of claims. Designating a person or team to be responsible for all aspects of workers’ comp administration can provide the needed oversight and to eliminate confusion about the process.

For Employees:

When a worker is injured on the job, they have to complete some paperwork in order to file a workers’ compensation insurance claim. Logically speaking, problems can arise such as:

Failing to report an injury in time If a claim is not reported on time this may be grounds for WorkCover to deny your claim. The responsibility lies with the injured worker to progress the claim, complete the appropriate forms, see a doctor and obtain your WorkCover – FIRST certificate of capacity.

A Certificate of Capacity is an official document that describes your injury, illness, capacity to work, and any limitations you must perform your regular work tasks.

If workers are unsure on how to progress a claim you should speak to your employers and employers should in turn speak to their relevant brokers or claims manager.

Also failing to provide medical information and full details of the accident report can lead Omitting critical medical information and details on the accident report, or failing to submit this information as part of a claim.

Errors in filling out forms or avoiding submission of requested forms.

Failure to submit to medical testing, including drug screenings or failing to submit information submitted by medical professionals that indicate the injury was not work-related can cause serious delays or denied coverage. Employees denied coverage may seek legal solutions, which can cause employers to face significant expenses in legal representation as well as sacrificing a considerable amount of time if this arises.

Workers’ compensation insurance is governed by rules and regulations to protect all concerned parties, whether that is an injured employee or their employer. By taking the steps needed to manage claims reporting, both the employer and employee can have a better outcome.

With the average recommended premium rates for 2022/23 set to increase this year, workers compensation premiums will similarly rise. As insurance brokers we play a significant role in helping employers to be aware of workers compensation and its statutory obligations.

While there is no simple or swift way to resolve unfortunate situations like workplace injuries, we do offer you solutions and can provide advice to help businesses understand and manage people risk.