Workers’ Compensation Claims Process
How The Claims Process Works
Workers’ compensation is an industrial insurance which every Utah employer, with 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 Industrial Accidents Division claims staff can assist parties by offering information and resources to resolve claim related questions or issues. 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 (800) 530-5090.
An injured worker reports the injury or illness to his/her employer immediately. (180 day reporting requirement of employees, link) If the injury or illness is beyond first-aid or a medical bill is generated for the medical service, the employer must report a First Report of Injury or Occupational Disease (Form 122) within seven days of being informed of the incident. Reporting of the incident should be done directly to the workers’ compensation insurance carrier, who in turn electronically reports the injury to the Industrial Accidents Division within fourteen days of that notification. (If an employer is self-insured they are required to meet the same reporting requirements as the insurance carrier.)
A copy of the completed report along with the Injured Workers’ Rights and Responsibilities (Form 100) should be provided to the employee.
The employer directs the employee to a designated preferred provider, or if there is no preferred provider, the employee may choose to see a doctor of his/her choice and should visit with a medical provider who accepts workers’ compensation insurance. The employer should also provide the employee with the name and contact information of the workers’ compensation insurance carrier, along with their policy number. This information is typically requested by medical provider upon check in.
The employee informs the medical provider the injury or illness is work related. The doctor is required to report the initial visit by completing and submitting the, Physician’s Initial Report of Injury or Occupational Disease (Form 123) to the Industrial Accidents Division. In addition a copy of the report should be provided to the insurance carrier, employer and employee.
The insurance carrier will open a claim for benefits once they have received notification by either receiving one or both reports from the employer, doctor or the Industrial Accidents Division. The insurance carrier is responsible to make a determination of compensability of the injury or illness within 21 days of having received notification. The carrier may file for an extension of the investigation with the Industrial Accidents Division, by submitting the, Insurance Carrier/Self Insurers Notice of Further Notification of Claim for an additional 24 days (Form 441).
Within the 45 days the carrier should have a determination of compensability of the claim.
If the claim is compensable, the Initial Statement of Insurance Carrier/Self Insurer with Respect to Payments of Benefits (Form 141) should be sent to the employee along with the initial indemnity payment if it is determined the employee will lose work due the injury or illness.
The insurance carrier should contact the employer to determine the rate of weekly pay the employee received at the time of the incident to determine the temporary total (link to definition) or temporary partial (link to definition) compensation benefit. If there are multiple employers, the employee should provide their employment history to the insurance carrier for additional wage consideration.
The insurance claims adjuster is responsible to oversee the life of the claim, and works directly with the employee as it relates to benefits, treatment plans, return to work and all facades related to the claim. Medical benefits related to the injury or illness should be paid directly by the insurance carrier or self-insured employer and cannot be paid directly by the employer.
If the insurance carrier denies compensability on the claim, the insurance carrier is to provide a copy of the Employee Notification of Denial or Partial Denial of a Claim, (Form 089) to the employee and the Industrial Accidents Division. The denial form should provide a general explanation for the denial and in cases in which an employee attended an Independent Medical Evaluation (IME), a copy of the physician’s final report should be provided along with the denial letter.
For denied benefits on a claim, the employee has the right to file an Application for Hearing, with the Adjudication Division of the Utah Labor Commission. Please contact the Adjudication Division for additional information at (801) 530-6800.