Claims Procedures
What to Do When an Injury Occurs
The first action when an accident with injuries occurs is to provide prompt medical attention. In order for us to assist you in the timely investigation and handling of your Workers Compensation claims, we ask that you report all losses to us, on the appropriate form, as soon as you are aware of them. This includes medical only, lost time, first aid cases and incidents.
Report accidents to your Claims Representative within 24 hours, providing the most thorough information you can
NHRMA Mutual Claim Handling Procedures
Once the First Report of Injury is received by NHRMA Mutual, the claim information is entered into our claim system and the claim is assigned to a Claims Representative. The employer will be sent an acknowledgement letter that provides the claim number and Claims Representative name for that claim. The Claims Representative will then begin their initial investigation into the claim. This investigation involves contacting the employer, injured employee, and physician. The employee will be interviewed and a statement detailing the facts of the injury may be taken. Supervisors and co-workers may also be interviewed.
As you learn more about the case, contact your Claims Representative to provide all relevant information. If there are any outside sources that may have caused or added to the accident, or a pre-existing condition that may have contributed to an injury, make certain that information is included in your report. When investigating, remember that your job is to determine the cause of the accident, not to assign blame.
Should you receive any legal notices regarding Workers Compensation such as letters of representation, complaints, or lawsuits, please immediately fax this information to NHRMA Mutual so that we may do what is necessary to protect your interests.
Claim Decisions Requiring Member Involvement
- Is the case going to be handled as a compensable claim?
If a claim is not clearly compensable or non-compensable, the Claims Representative will contact the member with a summary of the claim details, along with an option to accept or deny the claim. The Claims Representative will offer his/her expertise and recommendations.
- Should an Independent Medical Evaluation (IME) be performed?
If an employee has been treating for an extended period of time, or if a surgical procedure is recommended, the Claims Representative may want to schedule an independent medical examination or second opinion examination. The Claims Representative will contact the member and explain the need for the examination.
- Should case management be assigned?
A case manager acts as a liaison between the claimant, employer, Claims Representative and medical provider. Case management can be assigned on a full or limited basis. Before it is assigned, the Claims Representative will contact the member and explain the necessity for this service.
- Should surveillance be assigned?
This is normally the most expensive option of claim handling. The Claims Representative will contact the member to determine if there may be a reason for surveillance.
- Should this employee be considered for an early return to work program?
When an employee is released to return to work on a limited basis, the Claims Representative will contact the member to determine if this is a viable option.
- Should the case be referred to a defense attorney for handling?
Sometimes a case reaches an area of expertise that a Claims Representative cannot manage without legal assistance. A case must be referred when the claimant’s attorney files a motion for hearing and intention to proceed to trial. However, most cases can be concluded by the Claims Representative without the expense of litigation and attorney’s fees. Before any case is referred for defense activity, the member will be consulted.
- Should benefits be terminated?
If the Claims Representative finds that there are grounds for benefit termination, he will contact the member to discuss those options prior to making a final decision.
- Should we make a settlement offer? Amount? Stipulations? Appeal after trial?
Prior to making a settlement offer of any type, the Claims Representative will contact the member and explain the settlement options. Likewise, all activities that arise from these should be discussed with the employer. (For example: IME results, surveillance results, defense attorney’s opinion of case, case management reports, settlement negotiation status.)
Claim Representatives
Barb Kadow
Claims Supervisor
217.403.4905
Wendy Collins
Claims Representative
217.403.4903
Pam Allen
Claims Representative
217.403.4911
Debbie Bryant
Claims Representative
217.403.4907
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