The Compensation Claim Process From Start To Finish

• Jurisdiction: Maryland

I. THE COMPENSATION CLAIM PROCESS FROM START TO FINISH

A. Initial Claim Processing

All of the initial steps in processing a workers' compensation claim have been designed by the Workers' Compensation Commission so that the employee can be receiving medical and disability benefits as soon as possible without undue red tape or excessive paperwork.

1. Employer's report

a. Accidental injuries

LABOR AND EMPLOYMENT § 9-707(a) (2020 & Supp. 2021) (hereinafter LAB. & EMPL. § ___) requires that an employer (including a statutory employer) must file a report with the Commission within 10 days after receiving notice or knowledge of an accident causing disability for more than three days during the two-year period following the accidental injury.¹

The three days of disability need not occur within the 10-day period during which the claimant must give notice of the accident. It is an open question as to whether the three days of disability must be consecutive in order to require the employer to file a report.²

If the employer fails to file a report as required by LAB. & EMPL. § 9-707(a), limitations on filing a claim for accidental injury or death shall not begin to run until the employer's report is filed.³ Further, as of October 1, 2017, an employer who knowingly fails to report an accidental injury can be found guilty of a misdemeanor and subject to a fine not exceeding $500.

Employers should be advised that the best practice is to file a report for every injury occurring on the job, even if the injury does not immediately result in three days of disability.

b. Occupational diseases

Whenever a disability from an occupational disease occurs, it shall be the duty of the employer promptly upon obtaining knowledge or notice thereof to report such disability to the Commission.⁴ However, the employer's failure to do so does not extend the limitations period.⁵

The employer's report should be filled out with some care, especially if the claim is suspect. For example, the employer should use the words "employee alleges" if the employer has some doubt about the background of the occurrence causing the injury.

It is a good idea for an employer to file all employer's reports with the Commission because a claimant could lose more than three days from work due to the accident at some later point, and limitations would not begin to run until the employer's report is filed.

Ordinarily, the employer sends the employer's report to its insurance carrier which then conducts an investigation into the claim.

The employer and the carrier should set up standard procedures as to which of them will send the employer's report to the Commission.

Employers should also be sure to fill out the "Report of Wage Information" on the back of the employer's report (the 14-week wage statement). This will insure against a Commission order based on an improper wage rate.

2. Employee's claim for compensation

An employee's claim must be filed with the Commission before benefits can be properly paid by the employer/insurer. The employee may file his or her own claim electronically. The insurer, upon learning that the claimant has lost more than three days from work, should direct the claimant to the Commission website to file a Claim Form. Again, care should be used in the preparation of the claim form, especially in the following areas:

Claimant should list all of the injured areas, as the failure to list an injured area now will cause doubts if it is claimed at a later date.

A claimant should carefully recite the facts surrounding the occurrence because, as we have seen, not every occurrence constitutes an accidental injury under the compensation statute.

You must use WCC Form C1 to file the employee's claim. A new online claim form and procedures have been adopted by the Commission. Consult the Commission's website for instructions on how to file one properly.

If the claimant thinks he or she has already filed a "claim," make sure the claimant is not merely referring to the employer's report, because the difference usually is not appreciated by claimants.

The initial processing of the employee's claim is handled by the Commission's Information Support Division, which inserts a claim number (which should thereafter always be referred to in addressing any communication to the Commission) and the name of the employer's insurer, or self-insurer, and sends a computer-generated blue or green copy of the employee's claim to all interested parties.

At the first interview, ask claimant if he or she has received a "notice," which positively identifies a claim filed with the Commission.

Learn to appreciate the difference between the Commission's claim number (currently B-8xxxxx, or W-000000 for online filings) and an insurer's internal claim number, which could have a variety of forms. Don't think a claim has been filed with the Commission just because an insurer claim number has been established.

Always include the claimant's claim number and date of accident in the caption of all correspondence to the Commission (and to the insurer) as an effective backup against lost mail and delays.

When filing employee claims, it is especially important to properly identify the employer so that the proper insurer will receive early notice of the claim. Frequently the claimant's wage stubs (helpful in determining AWW) will help with proper employer identification.

In the event of the claimant's death due to the accident, an additional form should be prepared entitled "Dependent's Claim for Death Benefits."

If the claimant dies from causes unrelated to the accident but with benefits remaining to be paid, no new claim form is filed. In this situation, Regulation .06 requires the filing of a "petition" using the original claim number, which "shall contain a statement of the facts necessary to show the petitioner's right to receive" the remaining benefits, and which should include copies of birth, marriage, and death certificates as applicable.⁶

3. Identifying the insurer

The Commission's Information Support Division determines the proper insurer by access to the National Council of Compensation Insurance's Policy Issue Capture System (PICS), and this information goes onto the Notice of Employee's Claim.

4. Consideration date

When the employee's claim is filed, the Commission's Information Support Division establishes a "consideration date," which notifies the employer/insurer that the Commission will pass an award based on the evidence in the claim file unless the Commission is notified of the employer/insurer's desire to contest the case on specific grounds or issues.

If the employer/insurer is satisfied that the claim is in order, it will permit the "consideration date" to expire, at which time the Commission will pass one of two types of awards:

a. A "claim deferred" order, finding that the claimant sustained an accidental injury, but subject to further determination concerning any benefits payable (this is used where there is no allegation of lost time);
b. An "award of compensation," commonly called a "TT Order," directing the payment of compensation for temporary total disability during the continuation of the disability, and subject to a later determination of average weekly wages (assuming employer has complied with Rule .06)⁷ and the cut-off date of temporary total disability. The Commission has ruled that employers and insurers may terminate temporary total payments made under the automatic temporary total order at such time as they learn that the claimant has returned to work or upon receipt of a medical report authorizing a return to work. That is, it is not necessary to obtain a separate TT termination date order from the Commission. They should be aware, however, that attorney's fees could be ordered against them if their TT termination proves to be totally unwarranted.

The employer/insurer is required to give written notice to the claimant, accompanying the final TT payment, advising the claimant of the TT cutoff, the reasons therefore, and of his or her rights to a hearing.⁸

5. Initial duties of employer/insurers—contested cases

The employer/insurer's copy of the employee's claim form contains Form C40 Contesting Issues and a return mailer, showing the date the claim was filed at the Commission.

The employer/insurer must commence payment of TT benefits OR file issues contesting the claim within 21 days of the date the claim was filed, and mail the C40 to the Commission and interested parties. Failure to comply can result in a 20% penalty of benefits due, payable to the claimant; after 30 days, the penalty can be 40%.⁹ If the employer/insurer wishes to contest the case, it completes the issues on the back of the C40 Form.

The filing of issues constitutes a request for a hearing before the Commission. When issues are received, the Commission sets the case for a hearing before one of the Commissioners, who will decide the issues raised by the parties.

6. The Uninsured Employers' Fund

If the employer is not insured for workers' compensation, the Uninsured Employers' Fund (UEF)¹⁰ may ultimately pay benefits in the case. The Fund is represented by the Attorney General, and may be contacted as follows:

Uninsured Employers' Fund
Hampton Plaza, Suite 402
300 E. Joppa Road
Towson, MD 21286
(410)321-4136
fax: (410)321-3975
email: uef@qis.net

The Commission will notify the UEF where no insurance record exists for the employer.

You should continue to investigate the possibility that insurance exists, and investigate other avenues, such as a "statutory employer."¹¹

The UEF does not pay pursuant to the automatic award; there must be a separate order issued against them. They may raise issues after the consideration date. The claimant should send medicals to the UEF prior to a hearing.

Uninsured Employers' Fund claims are guided by a set of procedural regulations.¹²

The claimant must first seek payment of an award from the uninsured employer, after which the UEF...