Filing a claim for workers' compensation benefits can appear to be a very complicated process for employees whose employers may not be helpful, or who may not understand the process themselves.
Workers' compensation insurance is an industrial insurance which every employer, with very few exceptions, is required to purchase to cover work place injuries and illnesses for its employees. Since the workers' compensation program is a no-fault program, neither the employer nor the employee has to assign fault for an injury occurring in the workplace. The steps of how a worker’s claim for benefits proceeds in the system are as follows:
- An injured worker reports the injury or illness to his/her employer immediately. If the injury or illness is beyond first-aid, the employer must report a First Report of Injury within seven days, this is done by reporting the injury to the workers' compensation insurance carrier, who in turn electronically reports the injury to the Labor Commission. A copy of the report is to be given to the injured worker. This immediate notification allows the injured worker, employer and insurance carrier to promptly begin to have the injured worker receive the medical care needed to return to work as quickly as possible.
- The injured worker tells the medical provider that the injury or illness is work related. The injured worker must be seen first by the employer’s designated physician or medical facility if the employer has chosen a physician or medical facility. If there is no designated medical provider, or once they have seen the designated provider, the injured worker may choose to see a doctor of his/her choice. The doctor is to report the initial visit by “Physician’s Initial Report of Injury” (Form 123) of the injured worker to the Labor Commission, the insurance carrier and give a copy of the report to the injured worker.
- The insurance carrier will open a claim for benefits once they have received either one or both reports from the employer or doctor. The insurance carrier is to make a determination of compensability of the injury or illness within 21 days of having received the claim for benefits and can file for an extension of a total of 45 days.
- Compensable Claim. If the claim is compensable, and if the doctor determines that the injured worker will lose work time, the insurance carrier is to contact the injured worker and the employer to determine the rate of weekly pay that the injured worker is to receive for the time off work. All medical bills are to be paid by the insurance carrier or self-insured employer (an employer who is not self-insured is not allowed to pay medical bills directly). The injured worker is not to pay anything toward the medical care received. In most cases the claim for medical benefits is paid, the injured worker returns to work and the claim is ended.
- Denial of the claim. If the insurance carrier denies that the claim is compensable, the insurance carrier is to send a denial letter to the injured worker and the Labor Commission.
- Application for Hearing. If the claim is denied, the injured worker has the right to apply for a hearing at the Labor Commission to have an administrative law judge determine if the injured worker’s claim is compensable. While the workers' compensation claim is being decided the injured workers' private health insurance carrier can be required to cover his/her medical expenses. On the application for hearing form, Item 8 Coordination of Benefits with Your Private Health Insurance Company, must be completely filled out in order for this process to start. Please note, the injured worker is responsible for any co-pays or deductibles normally due under the private health insurance plan. The private health insurance carrier is not obligated to cover medical expenses until notice is given. For more information regarding the Utah Coordination of Benefits Act (Utah Code Ann. §31A-22-619.6, please see the Utah Labor Commission Adjudication website.
- Workers' Compensation Coordination of Benefits Untimely Payment. If an application for hearing was submitted with item 8 Coordination of Benefits with Your Private Health Insurance Company completely filled out, and the Adjudication Division determined the injury to be compensable under workers' compensation, if the workers' compensation carrier fails to make payment within the time frame ordered the Workers' Compensation Coordination of Benefits Untimely Payment Complaint Form should be submitted to the Industrial Accidents Division for review.
- Labor Commission Assistance. The Industrial Accidents Division has several intake staff, ombudspersons, and mediators to help claimants resolve claims without the need for a formal hearing. However, if the claimant has filed for a hearing, the case continues in the adjudication process until the case is either settled or heard by an administrative law judge. For assistance, an injured worker, employer, medical provider or insurance carrier may contact the Industrial Accidents Division at 801-530-6800 or toll free (in Utah) at 1-800-530-5090.