Claims management fundamentals

David Marchione
Time and technology have taught us different and safer ways of working, and have made us more efficient at managing time and resources. There are things we used to ‘get away with’ that are no longer acceptable or accepted in today’s workplaces. We are now able to, and are required to do more with less, and we know the end does not justify the means when it comes to working unsafely or taking short cuts.

Some things that have not changed in the last 50 years are the fundamentals of workers’ compensation claims management:

1. Report injuries on time. 

• Ensure that injuries are reported to the compensation board within the time limits set out in your jurisdiction. Failure to report on time can result in administrative penalties and/or prosecution.

• Ensure that supervisors provide information to those responsible for claims reporting. Employers are required to report an injury when they become aware of the injury. If a worker reports the injury to their supervisor, the company will be deemed to be aware as of the date the supervisor was made aware.

• Provide as much information as you can at the time of the initial report. Be sure to note any concerns you may have with the validity of the claim or injury reported, provide information about any prior related injuries or pre-existing conditions, and provide information about any third party who may have been responsible for the injury in order to maximize the possibility for minimizing costs.

2. Maintain communication with the injured worker.

• Contact the injured worker immediately following the injury and maintain communication with them while they are at the workplace or away from the workplace. Many workers become frustrated by a lack of communication from their employer if they are unable to work because of an injury.

3. Offer suitable work as quickly and safely as possible.

• Work with the injured party to identify suitable duties for them. Are they able to return to their pre-injury job without accommodation? If not, what type of accommodation do they need? If they cannot do their pre-injury job, are there other duties they may be able to perform?

• Engage the injured worker in this process and ensure their treating health care practitioner is aware of your ability to accommodate the workers’ functional abilities while promoting their recovery.

4. Monitor the worker’s recovery.

• Follow up with the injured worker to confirm what type of treatment they are receiving. How often do they need to attend? When is their next medical appointment? Have they been referred for any further testing or to a specialist? Will they require surgery? Has it been scheduled?

• Many employers think that they cannot inquire about the above. As an employer, you are not entitled to know the injured worker’s diagnosis, but you are entitled to know their prognosis and their functional abilities and limitations in order to facilitate a return to the workplace as quickly and safely as possible. Also, confirming dates for treatment can help you plan or accommodate the worker if they need to be away from the workplace for medical treatment.

• Injuries should heal over time. So, be sure to work toward facilitating the injured worker’s return to regular work as quickly and safely as possible. Obtain updated medical information to help with adjusting return to work plans to fit the worker’s recovery.

5. Appeal adverse decisions.

• Exercise your right as an employer to appeal adverse decisions by the compensation board, whether they are decisions on initial entitlement, or ongoing health care or wage loss benefits. Perhaps you have information that the board was not aware of when the decision was made, or perhaps the legislation or an applicable policy was misinterpreted. Adverse decisions can have a significant impact on an employer’s experience rating, premium payments or even their ability to obtain work through tendering processes.

• Ensure that appeal time limits are met and that sound arguments are made, presenting evidence as to why the decision should be in your favour.

By following the fundamentals, and ensuring that claims are managed from the outset, employers can minimize costs and the potential significant impact of workers’ compensation claims. The mistakes of our past can have considerable impact on our future, thus making it always important to stay diligent with claims management.