Elements of a claims
management program

DO YOU HAVE A CLAIMS MANAGEMENT POLICY?

We suggest a formal claims management policy be devised that clearly communicates the organization’s claims management philosophy and goals and outlines the policy program. The policy could include:
  • An explanation of the benefits expected from the program and the need for involvement of all employees.
  • Assignment of responsibilities to:
    •

    A claims management coordinator
    Department heads
    Supervisors
    Employees
    Committees

  • A clear statement of program goals.
  • A commitment and methods to evaluate the program.
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    DO YOU HAVE A CLAIMS MANAGEMENT COORDINATOR?

    This position is normally held by a safety coordinator whose responsibilities may include:
  • Coordinating all phases of the claims management program.
  • Preparing and analyzing claims management experience in reports to the chief executive officer and others designated by the CEO.
  • Consulting department heads on the administration of the claims management program.
  • Evaluating the program annually and recommending, if needed, changes in the program.

    • DO YOU HAVE A PRE-INJURY PLAN?

    You may want to develop a pre-injury plan that is communicated to all employees that gives complete information to be followed in case of an injury. The plan may include provisions for:
  • Steps to follow when a work-related injury happens.
  • A list of doctors available on emergency call and emergency service personnel.
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    DO YOU HAVE A DESIGNATED MEDICAL PROVIDER?

    You may want to consider a plan that provides for medical treatment and for determining an injured employee’s ability to return to work. That plan might include:
  • A list of medical providers available to treat work-related injuries.
  • Establishment of a working relationship with a selected medical provider who will work with you to provide treatment for employees immediately after an injury occurs.
  • A policy statement concerning the use of a designated medical provider. If you have selected a company physician, it is reasonable to send all non-life-threatening injuries to that physician for care as the initial medical attendant. If no designated physician is available, the employee may select the physician of his or her choice for initial treatment. Employees should be informed your business has a designated medical provider for work-related injuries.
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    CLAIMS COMMUNICATIONS

    Communication is key to ensuring that all parties involved in a work-related injury are aware of the current status, the prognosis, and the expected return-to-work date. Establishing work relationships and procedures between all involved parties to exchange information aids in the prompt and proper adjustment of claims and in returning injured employees to work as soon as possible. Provisions could include:
  • Claims reporting procedures.
  • Establishment of a claim adjustment working relationship between your organization and the State Insurance Fund.
  • Review of claim reports from the State Insurance Fund.

    • EMPLOYEE COMMUNICATIONS

    A plan that keeps up the morale of injured employees while off the job by providing continuing job and claim status information can have a positive impact on returning the employees to work in a timely manner and can help keep costs down. Communications with injured employees may include:
  • An explanation of benefits and procedures to the injured workers and their families.
  • Continuing contact with the injured employees involving supervisors, human resource representatives and State Fund examiners.

    • REHABILITATION

    A very important element of a good claims management program includes a plan to return injured employees to work as soon as possible and minimize the effects of the disabilities to the injured employees. This plan could include:
  • Establishing a light work or modified duty program.
  • Identifying light or modified duty positions.
  • Matching disabled employee capabilities to job physical and medical requirements.
  • Preparing an employee for a new position, if needed.

    • CLAIMS MANAGEMENT REVIEW

    Another important element of a good management program includes reviewing the overall plan to analyze its effectiveness in controlling the effects and costs of injuries and relating actual results to the predetermined goals. The State Insurance Fund provides a status report on all of the reported claims approximately 45 days after the end of each quarter and each policy year. This report will include information on the paid and estimated costs for each claim.

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    Idaho State Insurance Fund