Timeline of the “Typical” case: Admitted Traumatic Accident with Lost Time.
- Initial investigation to confirm loss.
- If there is medical and lost time, begin benefits.
- File FROI-00 (Electronic Data Interchange, “EDI”).
- File update EDI documents as the case progresses.
The Board’s initiative to enforce EDI (“eClaims”).
Beginning in 2013, the Board has begun an increased tempo of “monitoring and compliance” initiatives intended to enforce the eClaims guidelines and generate more penalty income for the State. The Board has now established a “Compliance Unit” intended to do the following:
- monitor performance standards for timely submission of First Report of Injury,
- confirm timely first payment of indemnity benefits,
- check for timely submission of Subsequent Report of Injury showing first payment,
- monitor timely submission of Controversy; and
- track the Percentage of Claims Controverted (how many cases is the carrier denying?).
Immediately: Medical Treatment.
An injured employee should immediately tell his or her employer or supervisor:
- When she was injured (the temporal);
- Where she was injured;
- How she was injured; and then
- Obtain medical treatment.
In addition, an employee must submit written notice to his or her employer within 30 days. WCL § 18. In real life, it often does not work out this neatly – often employees finish their shifts, go home, and get medical treatment without alerting the supervisor to an injury or reporting an accident.
Employers may not direct their employees to a particular health care provider unless the employer participates in a Preferred Provider Program or an Alternative Dispute Resolution Program. Employers can recommend care providing they inform employees of their rights to choose providers of their choice (Form C-3.1).
Self-insured employers, insurance carriers, and the State Insurance Fund are authorized to require employees to obtain diagnostic tests from approved and contract providers who are part of a network selected by the employer or carrier. WCL § 13(a)(7)(c). Employers may require employees to obtain prescriptions from a pharmacy with which they contract. WCL § 13(i). In both situations, notice must be provided to the employee.
Investigation and Communication.
All accidents should be investigated fully. The employer should contact the insurance carrier and maintain those communications throughout the claim. The investigation’s results should be copied to your defense attorney in the case of a controverted claim.
Any written contact with the claimant’s health care provider should be copied to the claimant and the claimant’s legal representative, if any. Any attempt to influence the health care provider in any way may be considered interference with the claimant’s treatment, which is a misdemeanor.
Minor Injuries.
For minor injuries, defined as “requiring two or fewer treatments by a person rendering first aid, and with lost time of less than one day beyond the end of the working shift on which the accident occurred,” the employer may pay for the first aid treatments directly (instead of referring the incident to the workers’ compensation carrier and the Board). Instead, the employer completes a Form C-2F “Employer’s Report of Work-Related Injury/Illness” but does not send it to the Board or the insurance carrier – they hold the form in their files for the statutory 18-year period. WCL § 110.
