Elements of a claims management program

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In spite of a good accident prevention program, some employees may be injured in work-related accidents. You may be able to minimize the extent of monetary loss to both your employees and your organization through a well-planned and well-run claims management program.

If you want to develop a claims management program and would like assistance, contact our Risk Management Department or your assigned risk management consultant.  

The following provides some basic components of a claims management program which, if implemented effectively, could have positive results for your organization.

Claims management policy

We suggest a claims management policy be developed that clearly communicates the organization's claims management goals and outlines the program.

 The policy could include:

• A commitment from management
• Assignment of responsibilities to:
  • A claims management coordinator
  • Department heads
  • Supervisors
  • Employees
• A clear statement of program goals and methods to evaluate the program
• An explanation of the benefits expected from the program and the need for involvement of all employees

Claims management coordinator

This position is normally held by a safety coordinator or human resource officer whose responsibilities may include:

• Coordinating all phases of the claims management program
• Analyzing claims management experience and preparing reports for 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

Pre-Injury plan

You may want to develop a pre-injury plan that is communicated to all employees and 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 occurs
• A list of emergency service personnel within the company

Designated medical provider

You may want to consider a plan that provides for prompt medical treatment and for determining an injured worker's ability to return to work. That plan might include:  

• Selecting a designated medical provider who will work with you to provide treatment for employees immediately after an injury occurs and to help determine an injured worker's ability to return to work
• 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. Employees must be informed your business has a designated medical provider for work-related injuries.
• Complete and submit a Designated Medical Provider form listing your designated provider.

  Designated Medical Provider form [Word]
  E-mail as an attachment to

  Designated Medical Provider form [PDF]

Claim communications

Communication is the 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 a working relationship with all parties involved aids in the handling of claims and in returning injured employees to work as soon as possible. Provisions could include:

• Claim reporting procedures (who reports what, to whom, when, where, and how)
• Regular contact between your organization, the designated medical provider, and the State Insurance Fund claims examiner
• Quarterly review of claim reports on the State Insurance Fund Web site.

Employee communications

A plan to stay in touch with injured workers while off the job can have a positive impact on returning the employees to work promptly and can help keep costs down. Communications with injured workers may include:

• Early and frequent contact with the injured worker to express an interest in their recovery, to determine their return to work status, and to keep them informed regarding return to work opportunities
• Providing information concerning the benefits available and how the process works. The claims examiner can provide information to you.
• Discussing other possible benefits available and the coordination of those benefits with workers compensation, if needed

Information for injured workers

Rehabilitation

A very important element of a good claims management program includes a plan to return injured workers to work as soon as possible. You may need to work with the injured worker, vocational rehabilitation consultants, the preferred provider, and the claims examiner to identify return to work opportunities.  A rehabilitation 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

A good claims management program includes reviewing the overall plan to analyze its effectiveness in improving organizational performance, controlling the costs of injuries, and relating actual results to the predetermined goals. Claim information is available on-line to registered users of the State Insurance Fund Web site. Registered users can view information related to the paid and estimated costs for each claim. The claim information can be downloaded to a spreadsheet program to sort and analyze as desired.

Consider offering modified duty

Modified duty means altering the current job to meet medical restrictions or temporarily transferring the worker to another job. Modified duty positions generally are not permanent. They are transition jobs. The bottom line is to bring the worker back to work in a position that meets the doctor's restrictions.

If an employer is considering a modified duty job, the employer should consult with the claims examiner. Job modification may need to be accomplished through the efforts of rehabilitation consultants working with the employer and the physician.

If an injured employee declines a legitimate offer of a modified duty job, which has been approved by the treating physician, there could be a basis to stop compensation benefits. The job should be offered in writing and have a written job description.

If the modified duty position pays less than the person's regular pay, the employer should inform the examiner. Temporary partial compensation may be payable.

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