What happens when you get hurt at work? Workers’ compensation is mandatory in most industries. Depending on the state where you work, anyone - full time, part time, contract, or seasonal workers - who works for your business can be eligible for workers’ comp. Some states require companies to cover more than one employee to have coverage, while others set the threshold between 2-5. Some industries or roles (like the Directors of a corporation) are usually excluded. Many other industries are required to have workers comp to operate in a legal way. So what happens when you actually have to use it? 

Step 1: Employer

When you get hurt at work, the first thing you should do is report it to your employer. They’ll be able to tell you the next steps - whether that’s seeing a physician prescribed by your insurance company or heading to your preferred doctor yourself. If the workplace injury is severe, or even fatal, the employer will need to report it within 8 hours. 

In some states, you’re required to see a doctor set out by the insurance company, while others will let you pick your own. When you arrive, usually the triage nurse or attending physician will ask whether or not the incident or injury occurred at work. They do this because if you’re hurt at work, you have a right to make a claim. The services that your physician provides to you will then be billed to the insurance company, but it depends on your state whether or not you can choose your own physician, or whether the insurance company will decide. 

This step is the first one in the ‘paperwork trail’ - the record of your injury will be kept as part of the workplace health and safety records, and there might be some paperwork generated in the form of emails between you and your employer, your employer and the insurance company, or the medical practice assigned to your claim. 

Step 2: Physician

Once you see a  physician, they’ll take a record of your injuries in order to assess and treat them. Doing this not only helps you recover, it’s also a necessary part of the claim. Having the physician assess the extent of your injuries will generate more information to add to the paperwork train. Previous health information, markers of impairment or injury, record of what happened, and the treatments they had to provide will all give the workers compensation body and your insurer more insight into what a ‘return to work’ will look like. 

For this part, doctors use a medical treatment utilization schedule (or utilization management tool, depending on the state) to assess the treatment required and billable part of your claim. Treatments for your injury must be approved on this schedule in order for you to file a claim. Will you need a continued hospital stay? Will you require surgery? All of the actions taken here will generate documents between yourself, your physician, your employer, and your insurance company.

Step 3: Insurance

Your physician prescribes treatment for your care and bills you for their time. It’s now up to the insurance company to get you back to work. They’ll now work with your employer to decide on the best option for your care going forwards. The parties involved usually want to get you back to work as quickly and safely as possible. There will be an underwriter or claims adjuster assigned to your case, and they’ll be the one who will now review the medical documentation the doctor provides. 

They can also interview your employer, any witnesses of the accident, or the doctor who treated you in order to get a clear picture of what happened and your medical history. This helps them generate an accurate estimate for your compensation - it also means they’ll be generating (and using) even more documents, as they communicate with the insurer, your employer, or any additional specialists (such as physiotherapists or home care nurses) necessary for you to get back to work. 

Step 4: Lawyers

You and your insurance company might not see eye to eye on the impact of the injury or the amount of time you’ll need to fully recover. Sometimes employers will question whether or not you actually needed to make a claim, or insurance companies won’t agree to pay for the full amount of treatment. 

In this case, you have a right to seek legal representation - lawyers who specialize in workers compensation will now take on the case, representing you in any negotiations with the insurance company. This is where the amount of documents related to your claim can be crucial: now that these documents are legal evidence, every detail of the medical reports, employer reports, or incident evidence collected by the insurance company are part of your lawyer’s evidence to support your claim and settle your case. 

Step 5: Independent Medical Examiner

Depending on the outcome of previous parts of the process, the insurance company might bring on an independent medical examiner (IME) to assess the validity of the claim, act as an expert witness, or provide an assessment of other factors attributing to the injury. Similarly to lawyers, this part of the process can generate even more paperwork, resulting in a lengthy and manual process reviewing the claim. 

It can also require the existing documents to be kept in detailed, easily accessible order. Since the IME will often produce an impairment letter or rating indicating the extent of the injury and the maximum medical improvement, these documents (and this process) can also be paperwork heavy. 

Of course, not every claim is going to go as far as the courthouse. In general, most medical claims providers (and employers) want you back to work in good shape. However, with medical documentation, every document matters, and the data piles up - and even if your injuries are relatively minor, it’s still important to have clear, easily accessible documents to give to the professionals handling your claim.