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Reporting Workers’ Compensation Claims

Submitting Workers' Comp Claims

Workers’ compensation is crucial to protecting employees, but it is often a source of contention among adventure sports employers because it comes with considerable gray areas. When is a claim compensable? How do we identify a fraudulent claim? How do we report a claim, and should we report all workplace injuries no matter how serious? Keep reading to find out how to determine when — and if — an injury is covered by workers’ compensation.

Workers’ Compensation Claim Requirements

The claim must meet all five of these requirements to be compensable:

1. Happened to One of Your Employees

The first requirement is in place to ensure it’s your employee filing the claim, not an independent contractor or vendor who works for themselves or a third party. Even if the incident occurs on your property, unless it is someone who works directly for you, the claim is not compensable.

2. Resulted in an Injury or Illness

Injury is not the only thing that can potentially be covered by  workers’ compensation. Illnesses could also qualify as compensable claims, but only if they are related directly to the job. The illness also must be caused directly by the working conditions to be covered in a  workers’ compensation policy.

3. Arose Out of Employment

This requirement means there must be a direct connection between the injury and the desire or attempt to further the employer’s business. If the employer benefits in some way, whether monetarily or otherwise, from the employee’s activity, then the claim meets this qualification.

4. Occurred in the Course and Scope of Employment

The employee must be at work when the injury occurs. This includes any place or location mandated or expected by the employer. So, when an injury occurs at the employee’s physical everyday work site, that employee must prove he or she was injured while actively engaging in the furtherance of the employer’s business.

A special provision called the “coming and going rule” maintains that benefits are denied for injuries received when traveling to or from work. Additionally, injuries arising out of transit from one work site to another, are compensable. This provision also requires that the actions leading to the injury of the employee in question be prompted by the aspiration to further the employer’s business interests.

5. Resulted in Impairment and/or Lost Wages

The injury or illness in question must cause the employee to be impaired in some way and lose wages from not being able to complete his or her tasks completely. It is also a compensable incident if the injury or illness results in impairment but without lost wages or vice versa.

Identifying a Fraudulent Claim

Studies commonly show that roughly 90% of all workers’ compensation claims filed are legitimate. However, it is still important to watch for these red flags that may indicate a fraudulent claim:

  • Filing multiple claims
  • Longer absences than anticipated by the employee, combined with an unwillingness to return to work
  • Unwillingness to be assigned to other, lighter jobs within the company or to complete partial duties
  • Constantly missing medical appointments
  • Employee will not provide the date, time or location of the incident that caused the injury
  • Employee has no recollection of services provided for related medical bills
  • Lack of witnesses to an accident or incident
  • Employee cannot produce specific information about the nature of the injury

If any of these red flags occur, it by no means makes the claim automatically fraudulent. These are simply guidelines to keep employers proactively evaluating the legitimacy of a workers’ compensation claim.

CBIZ Adventure Sports is Here to Help

Carefully evaluating workers’ compensation claims is crucial in helping your company save money and prevent fraud. As a small business owner, one of your goals is to reduce your risk as much as possible. Our coverage will help guide you through unforeseen losses.  Request a free CBIZ Adventure Sport Insurance quote  today.

This blog may contain scenarios that are provided as examples only. In an actual claim situation, coverage is subject to the terms, conditions and exclusions of the policy issued. The information provided is general in nature and may be affected by changes in law or the interpretation of such laws. The reader is advised to contact a professional prior to taking any action based upon this information.

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2 comments on article "Reporting Workers’ Compensation Claims"

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Elina Brooks

Thank you for letting us know that a workers' compensation claim will only be approved if the injury resulted from the job and has a direct connection to it. My friend works at a moving company and recently injured his back while in the middle of a job. I'll keep this in mind while I help him find an attorney to assist with his workers' compensation claim soon. https://www.davidhelfandlaw.com/workers-compensationb1f2268f


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Elina Brooks

It's a good thing you emphasized that a workers' compensation claim will only succeed if the injury has a direct connection to their line of work and occurred in the course and scope of employment. I heard about my friend being sent to the hospital recently since he ended up injuring his back while working for a moving company. I hope he finds a good lawyer to help make sure his workers' compensation claim gets approved soon. https://www.lawyerkatz.com/practice_areas/baltimore-work-injury-occupational-illness-attorney-james-katz.cfm

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