An Overview of the Workers Comp Claim Process
This Article Explains the Procedure for Claiming Workers Compensation
Compared to other types of civil litigation, the workers compensation process has more steps and variability. Even experienced attorneys find it complex and confusing.
This article simplifies the procedures for claiming workers compensation by providing a flow chart of the usual steps in the process.
Although no two claims are alike or follow the same path, the overview of the workers comp process below can help you recover more money, get the medical treatment you need to heal, and negotiate a lump sum settlement.
If you have questions, complete this form or call (804) 251-1620 or (757) 810-5614. You can also review our answers to workers compensation FAQs.
We have obtained results for hundreds of injured workers in Virginia and Maryland. See if we can help you.
Procedural Steps Applicable to All Workers Comp Claims
The steps below apply to all workers compensation claims, regardless of whether the insurer accepts or denies the case.
Employer Provides Notice of Injured Employees’ Rights under the Workers Compensation Act
The workers comp claim process starts before you suffer an occupational injury.
Every business covered by the Virginia Workers Compensation Act must post the notice in Form VWC1 in a conspicuous place where employees will see it. Other states have similar rules for employers.
Occupational Injury or Illness Occurs
Your work-related injury or the communication of a diagnosis of an occupational disease starts the workers comp claim process for your specific case.
Report the Injury to Your Employer
You must report a workplace injury to your employer within 30 days of the accident date. This letter can serve as a template for your injury report.
You may forfeit the right to workers compensation benefits if you do not report the injury within 30 days.
You Receive Medical Treatment
Medical treatment serves several purposes in the workers comp claim process.
First, medical treatment helps you heal and regain as much of your pre-injury functioning as possible.
Second, the Workers Compensation Commission often decides whether you meet the definition of “injury by accident,” have a disability from work that qualifies for wage loss payments, or suffered permanent impairment based on your medical reports.
Therefore, you must seek medical care immediately.
Employer Completes a First Report of Injury (FROI)
Virginia Code Section 65.2-900 requires every employer (or its insurer or claim administrator) to report a workplace injury or death to the Workers Compensation Commission within ten days of the injury or death.
This first accident report must include the following information:
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- The employer’s legal name, federal employer identification number (FEIN), type of business, address, and insurance policy number
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- The injured employee’s name, phone number, mailing address, occupation, date of birth, and sex
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- The accident’s cause and the nature of the injuries
An employer’s failure to file this required accident report tolls the statute of limitations for filing a claim.
The Insurer Contacts You
Although not mandatory, the insurer will likely call you once notified of your occupational injury or illness.
The workers comp claim adjuster may send you a list of doctors to choose from, ask you to give a recorded statement, and send an information packet containing a blank request to release medical records.
I recommend speaking with an attorney before doing any of these things.
Commission Sends a Notification of Rights
Once the Workers Compensation Commission receives the first injury report from the employer or claim administrator, the Commission will send you a letter entitled Notification of Injury.
This notice will enclose a claim form for you to complete and file, as well as a copy of the Commission’s Workers Compensation Guide for Employees.
You File a Claim
Submitting a claim for benefits to the Commission protects your rights and tolls the statute of limitations.
Your claim should state the benefits sought and whether you want the claim referred for a workers compensation hearing.
Commission Sends a 30-Day Order Claim Filed to the Employer/Insurer
Once the Commission receives your claim and medical records substantiating it, the Commission will issue a 30-Day Order to the employer/insurer.
The employer/insurer must complete and return an Order Response Form to the Virginia Workers Compensation Commission within 30 days or risk the imposition of sanctions.
Potential responses to the 30-Day Order include the following:
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- The insurer accepts the claim as compensable and attaches signed agreement forms or indicates the type of agreement form the employer/insurer will mail to the Commission.
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- The investigation is ongoing, identifying the information needed.
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- The employer/insurer denies the claim.
If the employer or insurer denies the claim, the Commission will docket it for a hearing before a deputy commissioner.
Process for Accepted Workers Comp Claims
The steps in this section apply when the employer/insurer agrees that you suffered an occupational injury or illness and should receive the benefits you claim.
Employer/Insurer Sends an Agreement to Pay Benefits Form to You
If the employer or insurer accepts your claim, they should send you a form entitled Agreement to Pay Benefits.
Once signed, the parties send this form to the Workers Compensation Commission.
Commission Enters an Award Order
The Commission will enter an Award of Benefits memorializing the parties’ agreement as detailed in the Agreement to Pay Benefits.
Payment of Benefits
You should start receiving the lifetime medical benefits and wage loss payments awarded within a few weeks of the Commission’s entry of the Award Order.
Lifetime Medical or Weekly Income Benefits End by Agreement, Opinion, or Settlement
The awarded benefits will continue until the parties negotiate a workers comp settlement, the Commission enters an opinion in favor of the employer’s application to stop benefits, or you sign a Termination of Wage Loss Award based on a full duty release or a return to work.
Workers Comp Claim Process When the Insurer Denies Your Claim
Accepted and denied workers comp claims share many of the same steps.
These extra steps apply when the employer/insurer denies your entitlement to benefits and says you cannot meet your burden of proof.
Pretrial Discovery Starts
The Rules of the Workers Compensation Commission in Virginia allow the parties to engage in extensive pretrial discovery.
You may use interrogatories, requests for documents, requests for admissions of facts and legal conclusions, accident site inspections, subpoenas, and depositions to probe the employer/insurer’s defenses.
Commission Assigns Your Claim to a Deputy Commission
Once the employer/insurer denies or ignores your claim, the Commission will refer your claim to a deputy commissioner.
This deputy commissioner will preside over pretrial motions and the workers compensation hearing.
Notice of Hearing Received
You should receive a Notice of Hearing soon after receiving notice of the deputy commissioner assigned to your claim.
This letter tells the parties the hearing’s date, time, place, and length.
Alternative Dispute Resolution (ADR) Offered
The judge may recommend the parties participate in issue mediation or full and final mediation with the Commission’s Alternative Dispute Resolution (ADR) Department.
Although the judge cannot force a party to participate in mediation, they can order the parties to participate in an ADR orientation session.
Hearing Held
At the hearing, which is workers compensation’s version of a trial, you must present evidence to support your claim for benefits.
The employer/insurer can likewise present evidence supporting their defenses.
Judicial Opinion Rendered
You will receive the deputy commissioner’s written decision, called a Judicial Opinion, within 30 to 60 days of the hearing.
Appeal to the Full Commission
A party has 30 days to appeal the Judicial Opinion to the Full Virginia Workers Compensation Commission.
Usually, the Full Commission decides the case based on the evidentiary record developed at the hearing and written briefs. However, the Full Commission may schedule oral arguments.
Appeal to the Court of Appeals
A party has thirty days from the publication date of the Full Commission’s opinion to appeal to the Virginia Court of Appeals.
Appeal to the Supreme Court of Virginia
Either party can file a petition for appeal with the Virginia Supreme Court.
The Virginia Supreme Court rarely grants petitions in workers compensation cases.
Your Attorney for Every Step of the Workers Comp Process
Understanding the workers comp claim process and your next steps are vital to winning your claim or negotiating a top-dollar settlement.
Contact us today for help with the process.
You pay nothing unless we obtain benefits or a lump sum for you.
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