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Ask Your Peers  The Legalities of Paying rather than reporting small WC claims 


David Leiser, Oxford Coverage, Inc. - Brooklyn, NY 11210
Reputation: 46 - Total posts: 5
What are the legal issues surrounding a company paying their small WC clamis and not reporting to their carrier in order to keep them from hitting their loss runs and negatively impacting their loss history, Experience Mod., ect.?
12 year(s) 2 month(s) ago
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Erin Carlson, CompleteMarkets - Jacksonville, FL 32224
Reputation: 7427 - Total posts: 245
Hi David,

From my understanding, the legal issues mainly revolve around the employer and the risk they run when not running the workers comp claim through their carrier. I do know that most (if not all) states require you to make them aware of the accident. The workers compensation insurance is required by law, but after some research I could not find any specifics on the requirements of going through your carrier only that an employer must carry the insurance. 

The employer is the one at extreme risk if they do not go through the proper channels for their workers comp claims especially if the employee decides to sue or needs life time care. I think the employer might run the risk of providing false information if they don't inform the carrier of the losses even if they pay out of pocket for the workers comp claims, so I am not sure how doing so would benefit them.

If the employer decides to pay out of pocket to keep it "off the books" and they do not disclose the losses during renewal/application they could face legal action from the carrier. I believe the carrier would still have to accept the claim but the carrier could come after the employer.

Keep in mind I'm no expert, this might be a question for a workers compensation lawyer.

Thanks! Great question!
12 year(s) 2 month(s) ago
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Joe Guyton, Watkins Insurance Group - Austin, TX 78759
Reputation: 10 - Total posts: 2
I have actually advised this strategy, however I am very clear to require the employer to submit a "for report only" claim to the company. The Stautary requirements in our state require this within 10 days. I have asked carrier underwriters about this practice, and have never recieved any clear or direct rational for reporting small claims other that it is necessary to calculate an accurate mod. I would be greatful for any other feedback regarding this practice.
12 year(s) 2 month(s) ago
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David Leiser, Oxford Coverage, Inc. - Brooklyn, NY 11210
Reputation: 46 - Total posts: 5
Thanks, Erin. I am also concerned of timely reporting requirments and late reporting exclusionary wording. I believe most policies address these items and many states have their own requirments which need to be endorsed to the policy via the state asmendatories. I believe you hit many of the points head-on - thank you. I seem to recall from a WC class I took eons ago that there are legal issues pertaining to not reporting claims in addition to the risk the insured is opening themselves up to. i just cant put my finger on anything and my searching has has so far come up dry.
12 year(s) 2 month(s) ago
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Jim McErlean, NSM Insurance - Redondo Beach, CA 90277
Reputation: 376 - Total posts: 49
I believe the legal angle only involves their OSHA 300 log - as long as the company is keeping a comprehensive compilation of all workplace injuries for their OSHA log, then they are compliant with the law. If they take the extra step of reporting the claim to their WC carrier as an "incident only", with no corresponding medical bills, there will be no impact to the Experience Mod. The only ramification is if an Insurance Company measures frequency as a strong UW characteristic, the Insured might face re-pricing or non-renewal due to loss frequency (but that would be a legit issue, as the claims actually occurred). Paying their small claims is a little bit like the concept of early "return to work" - in lieu of the Insurance Company paying for the indemnity portion of the claim, the Employer pays the Employee their regular wage out of payroll. Another angle you can compare the process of paying the small claims is an self-imposed deductible or a version of self-insurance. Therefore, it shouldn't be looked at negatively if the Insured is participating in the cost/process of their WC claims, as long as they are being 'reported' to the proper authorities (OSHA). Final thought, the Insurance Company has a vested interest in knowing the claims activity if one of these 'unreported' claims takes a wrong turn and becomes a more serious claim - therefore, you might want to communicate with the WC carrier on this potential change in your Risk Mgmt approach on small claims and even offer to send them a copy of your OSHA 300 log on a monthly/quarterly basis.
12 year(s) 2 month(s) ago
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David Leiser, Oxford Coverage, Inc. - Brooklyn, NY 11210
Reputation: 46 - Total posts: 5
Joe, a "for report only" or "notice only" to the carrier makes a lot of sense as it mitigates the risk assumed by the insured by putting the carrier on notice.
12 year(s) 2 month(s) ago
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Debbie Gates, Specialty Risk Insurance - Fidelity, MO 64836
Reputation: 15 - Total posts: 3
If you are in a state that allows the "deductible", and you are going to pay the small claims anyway, take advantage of the deductible credit you get on your premium. The credit is not large; however, every little bit helps. You will not only be saving on your exp mod, you will save up front on your premium.
12 year(s) 2 month(s) ago
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Red Hollingsworth, The Buckner Company - Holladay Ctwd, UT 84121
Reputation: 80 - Total posts: 9
David,

As Erin stated not notifying the carrier of a potential loss is not advisable and circumstances differ from state to state. In Utah if the employer has a contracted relationship with a clinic or medical facility the employer may pay directly for the services and not have the claim impact their work comp and experience modification. There are several important items that need to be in place: 1) There must be a contractual relationship between the Medical Facility and the employer. 2) The injured worker must receive their initial treatment from this facility with no more than one follow up visit. 3) There can be no prescriptions for any pain medication, over the counter drugs are permitted. 4) There must be a first injury report on file at the employers location.

There is some talk as to weather the report must be filed with the carrier at this time; the Utah Labor Commission is to be notified of the event and currently the carriers are the only ones who can file with the Labor Commission.

I know that the State if California has something very similar to this procedure, I would imagine that there are many states that have similar status and laws. You should contact the Industrial or Labor Commission in your area.

It is unlikely that there is a way to keep a injury even a small one off the books, the important issue is to understand how claims are managed in your state of the state where your clients are having claims and see what is the best way to mitigate them. I use a program call COMPMinder to help my clients manage their WC claims from a best practice position. It provides my clients with a protocol for managing claims, too many employers entire claims process is get the information to the carrier as quickly as possible.

Let me know if I can be of any help.

Red Hollingsworth
[email protected]
12 year(s) 2 month(s) ago
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Erin Carlson, CompleteMarkets - Jacksonville, FL 32224
Reputation: 7427 - Total posts: 245
If you do a "for report only" or "notice only" to the carrier, won't that still affect the loss history? If so I guess I'm not sure how it would benefit the employer to not file the claim through the carrier. 

Just as an FYI - For those of you who work with a lot of workers comp policies, you should look into premium recovery. We have a client that will review your clients workers compensation policies and if your client has over paid they will request a refund. In case you are interested :) 


12 year(s) 2 month(s) ago
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Joe Guyton, Watkins Insurance Group - Austin, TX 78759
Reputation: 10 - Total posts: 2
No, in my experience the "for report only" has a zero dollar loss, which is the foundation of the emod. a zero dollar loss calucates out to no effect on the mod. but as Jim mentioned earlier a company that has excessive "for report only" may impact the underwriting acceptance, but not the E-mod.
12 year(s) 2 month(s) ago
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Janice Mauriello  , Tracy Driscoll Co Inc  - Bristol , CT 06011-2060
Reputation: 10 - Total posts: 2
We have discussed this with many of our carriers and we do report the incident for records only. The carriers have told us that as long as there is zero payment by the carrier it does not get reproted on the insured statistical records for experience modification factor calculation.

The policy contract requires that the inusred report to the carrier. It also allows the carrier to review the type of claim and have a discussion with the insured if they feel it is the type of claim that tends to become a full blown claim based on their past experiences. In most cases they are right.
12 year(s) 2 month(s) ago
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Erin Carlson, CompleteMarkets - Jacksonville, FL 32224
Reputation: 7427 - Total posts: 245
Thanks Janice. Does it depend on the individual carrier or do you think most handle it the same way?
12 year(s) 2 month(s) ago
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Janice Mauriello  , Tracy Driscoll Co Inc  - Bristol , CT 06011-2060
Reputation: 10 - Total posts: 2
We find most of our carriers handle it the same way. Some of the smaller carriers my treat it differently. You should check with them individually. Our major players, Travelers, Hartford, Liberty etc.. are all similar in nature.
12 year(s) 2 month(s) ago
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David Leiser, Oxford Coverage, Inc. - Brooklyn, NY 11210
Reputation: 46 - Total posts: 5
Janice, your point is very well taken and addresses one of the main concerns - policy requirments. If a policy requires notification be given within a specified period of time, 30 or 60 days from date of event (subject to state amendatories), or "within a reasonable timeframe", noncompliance could seemingly result in coverage denial. Do you agree or do you think that coverage would have to be extended nontheless. The "within a reasonable timeframe" wording i have seen in some policies is very ambiguous and i am not sure how this would be implemented, i.e. how a reasonable time frame is defined. That being said, if an insured is made aware of a claim, makes payments to keep it "off the books" and only later, after it blows up, report to the carrier, i would think that their not reporting can easily be argued to be noncompliant with the "reasonable timeframe" wording.
12 year(s) 2 month(s) ago
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