How to make a claim under a workmen compensation policy?

How to make a claim under a workmen compensation policy?

Workmen Compensation policy is the primary solution for employer to safeguard themselves against statutory liabilities to their employees. With good workmen compensation policy, employers can exhibit their potential to meet the statutory obligations imposed by the Workmen’s Compensation Act, 1923. 

The workmen compensation policy covers employer’s liability to an employee in the event of workplace accident or illness leading to death or disablement arising out of or during the course of employment. Compensation payable under the policy is laid out as per the terms of the Worker’s Compensation Act, supervised by the Ministry of Labour. Following are the consequences covered under the policy –

  • Death caused in workplace accident or due to job-related illnesses
  • Permanent total disablement
  • Permanent partial disablement
  • Temporary (total or partial) disablement

Most of the workmen compensation policies even provide cover for medical expenses incurred for treating the injured employee and legal cost incurred by the employer. Click here to read about policy exclusions.

Though the policy works on ‘no fault’ basis, claiming the benefit from workmen compensation policy involves certain procedure. Before the claim process starts, every injured employee needs to be given/seek immediate medical attention. Once the primary aid and immediate medical care is given, process can be started to claim worker’s compensation.

Workmen compensation claim procedure

Before filing workmen compensation claims, remember that the primary medical care report serves as an official record for injuries sustained and works as a base for workmen compensation payments. However, Workmen Compensation statutes also allow employees to seek second opinion if they are not satisfied with the first one. Here is a simple process to follow for workmen compensation claim:

  • Notification to employer

First thing to claim workmen compensation benefits is to informing the employer about the injury or illness. Employee should report the workplace injury or illness caused due to work to the employer as soon as it occurs. Even after seeking the medical care and treatment, sometimes employee may have to see the medical practitioner within the insurance company’s network as a part of claim process.  Employee needs to give a written notice to the employer within the deadline mentioning all the details such as date, time, and place of injury, complete description of the accident or illness. Delayed reporting of claim may lead to claim denial.

To qualify for the workmen compensation claim, employee’s illness or injury needs to be job-related. Some of the workmen compensation examples are – slip and fall accidents at work, overexertion, machinery accidents, violence at workplace and accidents at construction zones etc.

  • Inform the supervisor

If the mishap takes place in the factory or manufacturing unit, then it’s important to inform the supervisor or factory supervisor immediately. 

  • Gather information

Once the reporting is done, employer must provide the relevant claim forms and list of documents required for claim to the employee. Employee needs to gather the information regarding workmen compensation benefits and about returning to work. Claim forms may vary depending on the type of illness or injury and insurance company.

  • Submission of documents

Employee needs to fill up the relevant claim form and submit it along with all the relevant documents to the employer. Requirement of documents may vary depending on the nature of claim. Following are the common documents required for workmen compensation claims.

  • Duly filled and signed claim form
  • Medical reports with details on injury
  • Statement of witnesses
  • Medical certificate with details of disablement (cause and anticipated recovery duration)
  • Death certificate, in case of death compensation claims
  • Post-mortem report
  • Memorandum of agreements as per Workmen’s Compensation Act, 1923 
  • First Investigation Report (F.I.R) from police, in case of death claims, etc.

 

  • Reporting to workmen compensation commission

On receipt of claim documents, employer should submit the details of compensation payable to employees to workmen compensation commission. Claim receipt will be then issued by the workmen compensation commission which needs to be submitted to the insurance provider.

  • Inspection of the claim

Once the employer submits all the claim documents to the insurance company, the company will appoint an official to carry out the inspection of the claim. It’s important to co-operate with investigator by providing all the information needed. Based on the inspection of the claim, report will be submitted to the insurance company.

  • Approval or rejection of claims

After verification of claim documents submitted and based on the inspection report, insurance company will accept or deny the claim. If the insurance company approves the claim, employee will be compensated for the loss of income, medical and legal cost depending on the compensation terms of Workmen Compensation Act, 1923. In case, the claim does not qualifies and the insurer rejects the claim, employee can appeal or ask the insurer to review the decision. The decision will be communicated to workmen compensation commission.

In case, employee returns to work after recovery, it becomes employers responsibility provide safety training and take preventive care measures to mitigate the risk of accidents.

Despite of implementing safety measures and risk control methods, accidents are still unavoidable at workplace. Workmen compensation policy safeguards both employer and employee during such unfortunate mishaps at workplace. It’s important to know the coverage offered, exceptions or exclusions in workmen compensation policy before claiming the benefits. Understanding the claim process helps to expedite the entire process of claim. To reap the maximum benefits, it’s also important to have the right workmen compensation policy. Click here to buy the right workmen compensation policy.

 

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