Step-by-Step Guide to Filing a Workmen Compensation Claim

A workmen’s compensation claim is a formal request made by an employee to receive benefits such as medical expense coverage, disability benefits, or death benefits after suffering a work-related injury or illness.

It provides financial support to the injured employee or their family, in return for giving up the right to sue the employer for workplace injuries.

Filing a workman compensation claim is a straightforward process if you have all the documentation in place. Any discrepancy or delay in the process can lead to a work cover claim.

Filing a workers' comp claim offers a financial cushion to the employee who suffered a workplace-related accident. Here are the key benefits of filing workers' comp.

Medical Coverage

One of the benefits of filing a workman's compensation claim is medical coverage. With the right insurance coverage in place, employees can avail of essential medical coverage, such as doctor visits, surgery fees, and more. This allows injured employees to focus on their recovery without worrying about the medical expenses.

Disability Benefits

Various workplace accidents or injuries can even lead to disability. Whether it is a partial or permanent disability, the workers' compensation insurance will cover it. The financial compensation will depend on the severity of disability or whether it is permanent or temporary.

Death Benefits

In some exceptional cases, workplace accidents or injuries can also be fatal, resulting in employee death. In such a tragic case, a workers' compensation policy provides financial benefits to the deceased employee’s family.

Lost Wages Compensation

Another benefit of filing a workman comp claim is compensation for lost wages. If an employee is unable to work due to a workplace injury, the policy covers a portion of lost wages during the recovery period. This ensures the employee can focus on healing without worrying about expenses.

Legal Protection

By filing a workmen’s compensation claim, employees receive financial support without the need to sue the employer. This provides legal protection for both the employee and employer, avoiding lengthy litigation while securing the employee’s rights.

Also Read: Workmen Compensation Policy Benefits

Filing a workers’ compensation claim is a straightforward process when the right steps are followed on time. It involves immediate action after the incident, fulfilling specific responsibilities, and submitting the required documents. Here, we will explain the key worker’s comp steps.

Step 1: Immediate Action by Employee

One of the key workers compensation steps is immediate notification. After a workplace accident or injury, there are certain actions that employees must take without delay. These actions include:

Report Accident: Injured employees must notify their employer of the accident as soon as possible. The reporting should include the date, time and how the incident occurred.

Get Medical Care: After reporting the accident to the employer, the employee needs to seek medical attention at an authorised medical facility.

Complete Paperwork: Employees must also complete the claim form, accident description, doctor’s report, and any other required documents.

Document Everything: Employees also need to document everything properly, including collecting incident reports, medical expense reports, and more.

Step 2: Employer's Responsibilities & Claim Submission

After receiving the employee's notification, employers need to take certain actions at their end. These actions include:

Provide Necessary Forms: The employer needs to provide the necessary claim form and other documents to the injured employee.

Notify Insurance Provider: The employer must notify the insurance provider of the workplace incident.

Submitting Claim: Once the employee provides the relevant document to the employer, the employer needs to submit it to the insurance provider.

Step 3: Investigation & Determination By Insurer

Once the employer files a worker compensation claim, insurance providers must follow the following steps.

Claim Investigation: The insurance provider will first investigate the claim request by verifying the claim report, documents and other things.

Claim Approval or Denial: Based on their investigation, they will either approve or reject the workers' compensation request.

Benefit Disbursement: If the insurance provider approves the claim, the employee will receive the required compensation in their bank account.

Step 4: Post-Approval & Ongoing Management

There are certain steps that the employer or employee needs to take after the approval of the claim, such as:

Follow Medical Advice: Injured employees need to follow all medical advice for a swift recovery, even after leaving the hospital.

Return to Work: Another responsibility of an employee is to resume work after recovery and to carry out the duties. Employers have the flexibility to modify duties based on employee capabilities.

Appeal (If Claim Denied): If the insurance provider denies the claim, the employer and employee can appeal the decision.

Also Read: Workmen Compensation Claim Settlement Process

Here is a list of workers' comp documents to submit when filing a claim, organised by category.

In Case of Minor Accidents

Duly filled worker compensation claim form

• Identity proof

• Employer’s ID proof

• Salary slip for the last three months.

• Evidence and proof of incidents

• Medical expenses report, such as hospital bills, prescriptions, etc

• Detailed report of the accident

• Payment proof of medical expenses

In Case of Death

• Copy of FIR

• Workmen's Compensation Act Form A

• Post mortem report

• Death certificate

In Case of Permanent Disability

• Report from the treating doctor about the percentage of disability

• Evidence and photographs of the injured person showcasing the disability

In Case of Temporary Disability

• Fitness or medical certificate from the attending doctor

• Leave certificate from the employer

There are certain things to keep in mind when filing a workers' comp claim to avoid rejection from the insurance provider. These pointers are:

Do Not Lie

One essential tip for filing a successful workers' compensation claim online is not to lie about the injury to the insurance provider. A worker or employee must be truthful about the incident. Any false information may lead to claim rejection and, in some cases, invite legal consequences.

Maintain a Record

Another crucial tip for successful workmen's compensation claims is to keep a record of the injury and its impact on working conditions. This documentation is helpful when filing a claim, as it helps insurance providers assess the injured person’s condition.

Proper Communication

Proper communication is also crucial for workers' compensation claims. By responding promptly to insurance provider or employer requests, employees can expedite the claim process.

Get Back to Work When You Are Well

Another thing to keep in mind for workers' compensation policy claims is to allow ample time for full recovery. Rushing back to work too soon may jeopardise one's health and affect the claim request.

Understand Your Rights

Lastly, it is crucial to know your rights while filing a workers' compensation claim. For instance, if the insurance company rejects the claim request, the employee can also appeal the rejection. Furthermore, if an employee is not happy with the compensation amount, they can also challenge it in court.

There are various reasons that can lead to the insurance provider rejecting the workmen's compensation claim. Some of the common reasons include:

Delay in Reporting

One common reason for the rejection of workers' compensation requests is the delay in reporting the incident. If the employee fails to report an incident to the employer on time, it may result in rejection. There are state-mandated timeframes for reporting incidents that must be followed.

Incorrect Information

Another reason for claim rejection is incorrect information on the claim form and on other workers' comp documents. If the information does not match the provided documents, it may result in rejection. The claim application needs to be properly reviewed to ensure all the details entered are correct.

Insufficient Medical Evidence

If, at the time of filing a workers’ compensation claim, an employee fails to provide the required medical evidence, such as a diagnosis report, treatment records, etc., it can lead to claim rejection. Insurers need all medical records to determine the compensation amount based on the severity of the accident.

Pre-existing Conditions

Claims can be rejected if the injury or illness is linked to a pre-existing medical condition that is not directly caused or aggravated by work-related activities. Insurers assess whether the condition existed before employment and whether the workplace incident contributed to it. If it is a pre-existing condition, it can result in claim rejection.

Intoxication

If the employee was under the influence of alcohol or drugs at the time of the accident, the workers’ compensation claim is likely to be rejected. Intoxication is considered a serious violation of workplace safety norms.

Employee Misconduct

Claims arising from intentional acts, negligence, or violation of company policies and safety rules may be denied. Insurers may reject claims if the injury resulted from the employee's wilful misconduct or unsafe behaviour.

Also Read: Top 10 Mistakes Employees Make While Filing Workmen Compensation Claims

To ensure that your workers' compensation claim is not rejected, you need to follow the steps below.

Report the Incident on Time

As soon as an incident occurs, employees must report it to their employer. Notifying about the incident promptly helps in establishing a clear link to work.

Seek Prompt Medical Care

Another step is to get medical attention right away. This is a crucial step that helps identify the severity of the injury. Ensure to get medical care from the authorised hospital.

Collect Necessary Documents

Proper documentation is also necessary for a successful workmen compensation claim. Try to document everything, collecting photographs and videos of the incident, to establish that the claim is legitimate.

Consult Attorney if Required

If your workers’ compensation claim is denied or rejected by the insurance provider for any reason, you can consult an attorney for legal guidance. An experienced attorney can advise on the next steps to strengthen or appeal your claim.

Filing a workmen's compensation claim is an essential step to get the compensation amount in the event of an accident or injury. However, to ensure your claims do not get rejected, you need to have workers' compensation documents in place. You also need to know the claim process and timeframes.

However, even after this, if your workmen’s compensation claim is rejected, you can seek guidance from an attorney. With the right approach and timely action, employees can protect their rights and ensure fair compensation.

Choosing a reliable insurer also plays a key role in ensuring a smooth claim experience. TATA AIG offers a workers' compensation insurance plan that helps employers navigate workers’ compensation claims more efficiently.

With our labour insurance plan, you will receive claim assistance when needed. Secure your business's reputation with our WC insurance policy.