What is the process for filing a workers’ compensation claim?
Getting the ball rolling on your claim starts with you, and keeping your claim moving forward requires staying on top of the claim with your employer and their workers’ comp insurance carrier.
After any work injury, or after you get diagnosed with an illness you believe is work-related, you need to notify your employer as soon as possible. This might not happen on the same day of the injury; your health comes first, and your chief concern should be in getting medical care, which might require an immediate trip to the hospital or urgent care.
Starting the claims process
As soon as you can after the accident, and within 30 days at the most, notify your employer of the accident, regardless of whether you need immediate medical attention or not. There should be a poster in the break room, locker room, factory floor or other conspicuous space letting you know who to report to and how. If you don’t see this poster, you can notify your immediate supervisor, human resources, or another managerial employee.
Within one day of notifying your employer, they should give you the Workers’ Compensation Claim Form & Notice of Potential Eligibility (DWC-1) or mail one to you. Complete this form and turn it in to your employer; they have one day to return a copy to you.
The employer will send the DWC-1 on to their workers’ comp insurance carrier. The insurance company has 14 days to acknowledge to you they have received the form. If you don’t hear from the insurance company within 14 days, check with your employer or call the insurance company directly to make sure they are in receipt of your claim and are processing it accordingly.
Getting medical care
As soon as your employer is notified of the injury or illness, they should send you to a doctor and authorize up to $10,000 in medical treatment. Unless you predesignated your personal physician to treat you for work injuries, your employer will send you to a doctor within the employer’s Medical Provider Network, if they have one. After your initial visit, you can choose a different physician within the network if you don’t like the first one you saw. You can switch a third time, as well.
The treating physician can clear you to return to work at full capacity or to perform appropriate light duty with work restrictions. The doctor might also deem you unable to return to work for a period.
The insurance carrier reviews your claim, accepts or rejects
The employer’s workers’ comp insurer has 14 days to review your claim and decide whether to accept it or deny it. They can also decide to take up to 90 days to make a determination. During this time, they can order a Panel Qualified Medical Examiner (PQME) to examine you and render an opinion that might be the same or different from your treating physician. Workers’ compensation pays your medical bills during this period up to $10,000.
If your claim is rejected or you have a dispute with the carrier over your treatment or benefits, you can open a case with the Workers’ Compensation Appeals Board (WCAB) at the Division of Workers’ Compensation (DWC). You’ll need to file an Application for Adjudication of Claim to open a case and get a case number. To request a conference at your local WCAB office, file a Declaration of Readiness to Proceed along with your correspondence with the insurance company, medical records, and other information relevant to your case. A workers’ compensation attorney can help you navigate this process, prepare your application, gather information, and represent you in any hearings or appeals that might be necessary to ensure you get the workers’ compensation benefits you are entitled to.
