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Claims Handling Performance

by | Aug 23, 2015 | MAD News |

COMPLIANCE MONITORING, AKA “CLAIMS HANDLING PERFORMANCE” – THE BOARD IS WATCHING YOU PART I

The board has created a new Monitoring Unit with a stated mission of promoting excellence and claims handling practices and to provide system participants in the general public with information as to claims handling performance.

Role of the Board’s newly created Monitoring Unit which will be monitoring the following

  • Timeliness of the First Report of Injury (FROI)
  • Timeliness of Initial SROI showing Initial Payment
  • Timeliness of Initial Payment of Compensation
  • Timeliness of Controversy
  • Percentage of Claims Controverted

Timeliness of the First Report of Injury (FROI)

WCL § 110(2):

An employer…shall file with the..board and with the carrier if the employer is insured, upon a form prescribed by the chair, a report of any accident resulting in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid…

This is the C-2F.

Rule 300.22 also requires a FROI:

The First Report of Injury, FROI, must be filed electronically:

On or before the 18th day after the disability event or within 10 days after the employer has knowledge of the disability event, whichever period is the greater

300.22(a)(1) defines “disability event”

…any accident, including death resulting therefrom, occurring in the course of employment or any alleged accident, including death resulting therefrom, that results in personal injury which has caused or will cause a loss of time from regular duties of one day beyond the working day or shift on which the accident or alleged accident occurred, or which has required or will require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid; or any disease or alleged disease, including death resulting therefrom, claimed to have been caused by the nature of the employment and contracted therein.

The Board will only be measuring timeliness of the FROI on lost time claims and is interpreting the time limitations from 300.22 as giving up to the GREATEST following to file the FROI when there is lost time:

  • 18 days from Date of Accident
  • 10 days from Date Employer had Knowledge of Injury
  • 10 days from Initial Date of Disability,

Hence on lost time cases it appears that the Board will not be finding a FROI untimely if the claim results in lost time and the FROI is filed within 10 days of when the employer knew there was lost time even though it might be filed more than 18 days after the disability event or more than 10 days after the employer knew that the injury was going to “require medical treatment beyond ordinary first aid or more than two treatments by a person rendering first aid.”

The fields on the FROI that capture these dates are:

  • DN0040 Date Employer Had Knowledge of the Injury and
  • DN0281 Date Employer Had Knowledge of Disability.

It also appears that the Board will impute knowledge based on the filing of a Notice of Case Assembly and Notice of Indexing.

Here is the math measured from the received date of the FROI:

  • Date Of Accident + 18 Days;
  • DN0040 Date Employer Had Knowledge of the Injury + 10 Days;
  • DN0281 Date Employer Had Knowledge of Disability + 10 Days;
  • Assembly Notice Date + 10 Days;
  • Index Notice Date + 10 Days;
  • DN0056 Initial Date Disability Began + 10 Days.

The latest of these days will be used to determine of the FROI is timely.

PRACTICE TIP:  “Disability” should be narrowly construed.