Processing a Workmen’s Compensation Claim By Virginia Jack
There are several aspects to Workmen’s Compensation, all of which cannot be outlined in one commentary. The focus of this article however will be on the procedure to be followed when submitting workmen’s compensation claims.
The passage of Section 24(1) of the Workmen’s Compensation Act 1960 on March, 1997 made Workmen’s Compensation insurance compulsory for all employers except the Government of Trinidad and Tobago.
Notification of claims is very important and should be made to insurers as soon as possible, usually within 30 days from the date of the incident. Insurers usually stipulate whether this should be in writing or verbal or if both methods are required. The completed claim form should follow immediately after verbal notification. Other supporting documentation which may include signed compensation receipt forms, injury leave certificates, fitness certificates, medical bills/receipts, medical and/or reports assessments or death certificate should be submitted with the claim forms if available; or as soon as they are acquired or completed, however at no time should you wait to acquire all documentation to present a completed claim.
This gives a brief description of the incident, particulars of the employee and information on the wages paid 52 weeks prior to the date of the incident, which is in accordance with Section 6(1) of the Act.
These are issued by the medical practitioner and come in two forms, the medical certificate – stipulating the period of leave granted and the fitness certificate, which states the employee is fit to resume work from a specified date.
Compensation Receipt Forms
Every injury leave should have an accompanying compensation receipt form for the stated period. The compensation receipt form, which can be obtained from the insurer or broker, evidences that the employee was paid compensation for the period of the injury leave or temporary disability in accordance with the Act. This form provides information on the amount of compensation received for a particular period of incapacitation by an employee. Payment of Compensation should represent 2/3rds of the employee’s average monthly earnings and is calculated as: –
Wages paid 52 weeks prior to injury ÷ 12 mths = Average monthly wage ÷ 30 days = Average daily wage × 2/3 = Compensation payable × number of days incapacitated (normally stipulated by the injury leave)
It should be noted that an employee on medical leave as a result of an injury sustain on the job no longer receives wages or salary but receives compensation in lieu of regular wages or salary.
The employee’s signature is also an important part of this form as it evidences acknowledgement of receipt of compensation in accordance with the law by the employee. If these forms are not signed, a disgruntled, injured employee can make a case at a later date against the employer for non-payment of compensation, although the employer continued wages or salary payments during the period of incapacitation. In event of any lawsuit or compensation for Permanent Partial Disability, this document would prove to be quite useful.
Section 16(1) of the Act provides for medical expenses not exceeding a sum of $500.00. This amount is normally the limit on most policies at no extra cost to the employer. However, this limit can be increased for an additional premium. To claim for this benefit from insurers, the medical bills and receipt evidencing payment is required.
Compensation is payable according to Section 9(1) of the Act where the death of a workman has resulted from any injury or accident during the course of employment. A Death certificate is required y the Insurers to determine the actual cause of death, to verify the time, date and if associated with the course of the employee’s job.
Detailed Medical Reports are required depending on the extent of injuries. These reports however, should be submitted approximately every three to six months, depending on the severity of the accident. This document assists the insurer in determining the actual extent of injuries as well as gives an indication of the period of further incapacitation, thereby enabling the insurer to set a proper reserve amount payable in total for the claim. This is also necessary, in order for employers to obtain reimbursement of compensation from Insurers in many instances of protracted injury leave.
Medical practitioners on request or when they determine it necessary provide Medical Assessments, which determine the extent of the employee’s injury in terms of disability percentages. Under Section 5 of the Act, there is the provision of compensation in event of death (copy of death certificate required), permanent partial disability (PPD) and temporary disability. The PPD is calculated based on the average monthly wage, the employee’s age, the PPD percentage and the amount of compensation paid to the employee. The employee or employer can disagree with a PPD assessment by the attending physician. When this occurs an application can be made to the court for the appointment of a medical referee, whose determination of the assessment is final.
After an employee is assessed either by a medical referee or a medical practitioner with a PPD, there are legal forms that must be completed. These include the Form E – The Deposit of Compensation for Non-Fatal Accidents, signed by the employer and the Form P – Memorandum of Agreement signed by both the employer and employee. The completed forms are submitted to the insurer, who submits the forms and settlement cheques to the Registrar of the Supreme Court. Insurers normally close their files at this point, as they have no control over payment of this money to the employee. The PPD payment to an employee is calculated as follows:
PPD amount = Average monthly wage x 48 months x PPD % – compensation paid. The minimum amount payable is 50% of 48mths x PPD%.
The Accounts Department of the Supreme Court contacts the employee to sign their contract of agreement. After this document is signed, the Department then arranges for the cheque and relevant documents to be forwarded to the Government Treasury. This procedure may take as long as three to four months. The actual settlement cheque made payable to the employee is issued and returned to the Accounts Department for collection by the employee.
The involvement of a medical referee tends to prolong the whole procedure mainly due to the length of time to obtain medical reports from the referee. This process may take an additional 3 months to finalize.