Claims Management

Compensation Claims Management

If an employee has an illness or injury and requires time off, he or she should be given the same opportunities to return to work as any other employee, regardless of how he or she became ill or disabled.

Ideally, lost time will be prevented in the first place, if at all possible. If interviews and the accident review show the employee can perform some duties, every effort should be made to avoid lost time. If medical treatment is required, the functional abilities form should be used to guide initial placement.

If there is lost time, the claims management process itself involves many stages, from claim receipt until the employee returns to work:

  1. Claim receipt: once paperwork is submitted it is stamped, registered as received, forwarded to an adjudicator and assigned a claim number (“identification”).
  2. The eligibility of the claim is assessed in accordance with the applicable policy, such as workers’ compensation legislation, company policy or insurance company contract provisions. For occupational injuries, employees must have been injured in the course of employment and have experienced lost time or required medical aid. For non-occupational illness, eligibility may depend on employment status, level of employee coverage, policy date, etc.
  3. Even with meeting the requirements in (2), the claim could still be denied if disability plan exclusions are applicable, such as stress (if not post-traumatic with WCB), cosmetic surgery, pre-existing conditions, other insurance policy clauses. If declined, wages and medical expenses are not covered.
  4. If deemed eligible in (2) and the exclusions are not applicable, medical documentation will be reviewed to determine if it is sufficient to disable the employee from the performance of their occupation (“information collection”). The Disability Management (DM) practitioner would evaluate all factors that may influence the case outcome, review job description and job demands analysis, barriers to the return to work, etc.
  5. If declined in (4), the employee can either return to work without recovering lost wages and medical expenses, or can appeal. To appeal, the employee must provide additional medical information that is new and has not yet been reviewed.
  6. If medical documentation shows the employee is in fact disabled from the performance of their occupation, the claim is approved for a specific time period. Once the claim is approved, case management can commence (“planning”). This involves interacting with the employee, the workplace and the health care community to ensure prompt and appropriate care, while maintaining an appropriate level of confidentiality. Case management strategies are appropriate for illnesses or injuries that go beyond a short duration absence with a well-defined acute episode (i.e. a flu lasting several days). Throughout this on-going process, the DM practitioner identifies any red flags or barriers that may impact the return to work process. Preferred health care providers will often be utilized to ensure the employees receive appropriate care. If a second opinion is needed for complex cases, an Independent Medical Evaluation or Functional Abilities Evaluation may be utilized as well.
  7. Once the time period in (6) is approaching its end, additional medical information will be required and reviewed to determine whether ongoing entitlement to benefits is warranted, or if the employee can return to work. If the work absence continues, the claim management process continues as well.
  8. If the employee can return to work, the DM practitioner reviews the essential duties of the job and matches to the employee’s capabilities, in order to transition back to work. This will ensure there is a reduced risk of re-injury. Return to work (RTW) dates must be communicated promptly to the supervisor or manager to allow for appropriate scheduling of the workforce. If the RTW is transitional or modified, a clear RTW plan must be established based on the capability of the employee to perform essential duties of the job. Progress back to regular duties should be monitored from the medical standpoint, and in terms of the workplace. Some employees, if disabled or have become physically weak during a long absence, may require work conditioning to improve physical tolerance to job related activities.
  9. If the employee cannot return to work to the previous job or the same workplace, rehabilitation alternatives should be explored (transferable skills, aptitude testing, educational factors, etc.)
  10. Throughout these processes, the DM practitioner should collect statistical data to support the program and demonstrate the cost effectiveness of interventions and ability to meet targets and goals.
  11. Once the goals have been achieved the case can be closed. For the employee and employer benefit, there should be an acknowledgment or celebration that the case is closed and goals have been met.