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Handling a Claim: Employer and Employee Responsibilities

When an employee is injured while at work, there are certain procedures which must be followed and responsibilities which both the employer and employee must fulfill in order for things to proceed smoothly. Although the specifics of the laws will vary from state to state, there are some general responsibilities which apply across the nation.

Employer Responsibilities:

  • You are responsible, first and foremost, for attempting to avoid workplace injuries by providing your employees with a safe place to work.

  • If an employee is injured, you are responsible for making sure that a First Report of Injury, or other similar document, is completed and forwarded to your workers' compensation carrier.

  • You are responsible for making sure that you do not violate any laws or rights of the injured employee. If an injured employee needs medical attention for a serious injury, allow them to see the company doctor or leave work to see their own doctor.

  • You are responsible for cooperating with your workers' compensation carrier, and their attorneys, in investigating the matter. It is likely that these parties will need documentation from you of the injured employee's payroll history. They may request a copy of the injured employee's personnel file. They may ask to speak to the injured employee's supervisor or co-workers to confirm the injured employee's story. Provide them with timely assistance. If you are contacted by an attorney for the employee, inform your workers' compensation carrier or their attorney. Do not provide documents to anyone else. Let your carrier and their attorney take care of those requests, if appropriate.

  • You are responsible for welcoming an injured employee back into the workplace once they are physically ready to resume employment. You may not penalize or terminate an employee for the mere fact that they have filed a workers' compensation claim. If you do, you may face serious civil or criminal charges.

  • You are responsible for assisting your state workers' compensation board in curbing fraud. Most people are aware that an employee can commit a fraud by lying about an injury, or exaggerating symptoms. However, employers can also commit workers' compensation fraud. For example, you cannot fail to provide your carrier with First Reports of Injury in the hope that if you keep your claims history down you will avoid an increase in premiums or headaches. However, it will not take long for your injured employees to figure out why they are not getting the benefits they are entitled to.

Employee Responsibilities:

  • Act responsibly while at work. You will not be entitled to workers' compensation benefits in situations such as where you have been injured while intoxicated at work, injured while in the commission of a crime at your work place or injured when you knowingly violated a policy or code which specifically prohibited you from engaging in the activity which caused your injury.

  • Example: You decide to hide behind a piece of machinery and smoke a marijuana cigarette while you are supposed to be working. As you are walking back to your work station, you run into a sharp corner, seriously cutting your arm in the process. Your injury would not have occurred but for your altered state. You will have a difficult time receiving workers' compensation benefits for your injury.

  • If you are injured at work, you should immediately (or as soon thereafter as possible) report your injury to your employer or immediate supervisor. Your employer is required to fill out a form, sometimes called a "First Report of Injury," for every injury which occurs in the workplace. Make sure that your employer fills out a form for you. Review the form to make sure that it is accurate, and request that you be provided with a copy for your own records.

  • Example: You injured your back in January of 1997 while at work. You only went to see a chiropractor a few times, and you didn't tell anyone about the incident because you didn't lose any time from work. Three and a half years later, your back starts to hurt in the same place. You think it may be related to your injury in January of 1997, but you will likely have a difficult time in obtaining benefits because you didn't provide notice to your employer within a reasonable time.

    Note: Not all injuries manifest themselves in the same way. It is easy to figure out your date of injury if you receive an obvious physical injury, such as a broken limb or severed finger. However, if you sustain a repetitive stress injury, such as carpal tunnel syndrome, which develops over time it may be harder for you to pinpoint what your "date of injury" is. In those situations, your are required to report your injury as soon as possible after you discover that it is related to your employment.

  • If you need medical attention, seek it immediately. What may initially be a minor injury may only increase in seriousness if you fail to go to the doctor for treatment. You are also responsible for following your doctor's orders.

  • Example: You have injured your back at work and your doctor tells you that under no circumstances should you lift more than twenty pounds for three weeks. Do not go home and immediately begin rearranging your furniture, carrying coffee tables and armchairs to and fro.

  • Be responsible with information that you receive from your employer regarding your injury, correspondence and forms you receive from your employer's workers' compensation carrier or records which you receive from your doctor. These are all important pieces of information and should be safeguarded for future reference and need.

  • Cooperate with any requests which are made of you by the insurance company. If the insurance company asks you to be seen by a physician of their choosing for an "independent medical examination" or IME, agree to be examined. It does little for your position, but raises many suspicions, if you refuse to be seen by any medical provider other than the doctor of your own choosing. In addition, in some states you can be penalized for failing to keep appointments with doctors chosen by the insurance company.

  • Be responsible in how you act, both at work and outside of work, once you have been injured. Insurance companies have been known to hire private investigators to follow and videotape employees who claim to have sustained workplace injuries. Insurance companies won't go to this length with all employees, but may be more tempted to do so if they already have suspicions of your claim. If you have made up an injury, or if you are exaggerating your injuries, you may face serious problems if you are caught.

  • Example: You claim that you have been injured at work and that you cannot walk, at all, as a result of your injuries. Unfortunately, your employer has just received a surveillance videotape which shows you sliding into third base at your weekly softball game. Oops. You will either not receive workers' compensation benefits, or will have to pay back benefits which you already received. In addition, you could face charges of workers' compensation fraud.

  • You are responsible for determining, in some sense, how your claim will proceed. You are not required to hire an attorney to assist you, but it is advisable, particularly if there are a large amount of benefits at stake. Worker's compensation is a unique and complex area of law which, in some regards, involves mathematics as much as the law. Benefit calculations can be incredibly difficult. Having an attorney who has a good understanding of the law will help to ensure you get the benefits to which you are entitled.

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