604.7 Filing Worker's Compensation Claims

600 Human Resources

604 Benefits

604.7 Filing Worker's Compensation Claims

Policy and Procedure Statements

Accidents Resulting in Injuries - When an on the job accident results in any loss of time or outside medical costs of more than $800, the necessary Worker's Compensation forms need to be completed in addition to the Supervisor's Report of Accident Investigation. All Worker's Compensation forms should be submitted to the University Office of Safety and Workers' Compensation .

Since Appalachian State University is a State institution, it is self-insured and bears all the expenses of approved Worker's Compensation claims. Claims requiring Industrial Commission approval are filed directly with the N.C. Industrial Commission by the University instead of through an insurance carrier.

Claims Filed With Industrial Commission - Worker's Compensation claims resulting in medical costs of $800 or less and no lost time are approved and paid by the University without being filed with the Industrial Commission. However, if a disapproved claim is questioned by an injured employee, the employee may request that the claim be filed with the Industrial Commission for a ruling. In this case, the necessary Industrial Commission forms must be completed regardless of the value of compensation.

PREPARE SUPERVISOR'S ACCIDENT REPORT FORM

Procedure Steps - North Carolina General Statute 97-22 requires an injured employee to give his or her employer a written notice of an accident. The completion of the Supervisor's Accident Report Form fulfills this requirement.

Refer to Human Resource Services Procedure Statement 5, Filing the Supervisor's Accident Report Form , for instructions on completing this required form. The completion of the Supervisor's Accident Report Form is required for every job related accident, no matter how slight.

The following forms may be obtained from the University's Web Site:

PREPARE I.C. FORM 19, EMPLOYER'S REPORT OF INJURY TO EMPLOYEE

This form must be completed and filed immediately with the University Office of Safety and Workers' Compensation when either of the following circumstances exist:

• Injury results in medical expenses in excess of $800.
• Physician's approved absence from work due to injury or occupational illness.

The injured employee's supervisor should complete the Employer's Report of Injury to Employee, I.C. Form 19, in the following manner:

• Fill out an original.
• Complete the form with the requested information.
• Supervisor should keep one copy and forward the original to the University Office of Safety and Workers' Compensation.

PREPARE I.C. FORM 18, NOTICE OF ACCIDENT TO EMPLOYER

The completion of the Supervisor's Accident Report Form fulfills the requirements of I.C. Form 18 for most accidents. However, if the injured employee wishes to challenge the disapproval of a claim by the University or the Industrial Commission, he/she should complete I.C. Form 18,, to be filed with the Industrial Commission in the following manner:

• Fill out an original and three copies. Form should be typewritten when possible.
• Form must be filed within 30 days of the accident.
• Complete form with the requested information.
• Employee keeps one copy of the completed statement, forwards one copy to the University Office of Safety and Workers' Compensation and files original and one copy with the Industrial Commission.

PREPARE I.C. FORM 25P, ITEMIZED STATEMENT OF CHARGES FOR DRUGS

An employee is entitled to be reimbursed for drug expenses related to her/his Worker's Compensation injury or illness. This reimbursement is obtained by completing I.C. Form 25P.

• Employee completes the I.C. Form 25P, listing the requested information for each drug purchase.
• Employee must sign form in appropriate blank to certify that the drugs listed are related to a Worker's Compensation injury or illness.
• Employee forwards completed form and receipts for drug purchases, if any, to the University Office of Safety and Workers' Compensation.
• All expenses for authorized drugs, travel, ambulance and nurses are paid by the University with a copy sent to the Industrial Commission. Reimbursements are forwarded to the University Office of Safety and Workers' Compensation for disbursement.

PREPARE I.C. FORM 25T, ITEMIZED STATEMENT OF CHARGES FOR TRAVEL

An employee is entitled to mileage for medical treatment due to a Worker's Compensation injury or illness. The reimbursement rate is $.20 a mile one way, beyond a 10 mile radius from point of origin. If an overnight stay is medically authorized, the following items will be approved as rendered:

• Motel Expense
• Meal Expense
• Parking and Cab Expense

This reimbursement is obtained by completing I.C. Form 25T.

• Employee completes the I.C. Form 25T, listing the requested information for each qualifying trip.
• Employee must sign the form in the appropriate blank to certify that the travel is related to a Worker's Compensation injury or illness.
• Employee forwards completed form and receipts for the "Other Expenses" claimed on the form to the University Office of Safety and Workers' Compensation.
• All expenses for authorized travel expenses are paid by the University with a copy sent to the Industrial Commission. Reimbursements are forwarded to the University Office of Safety and Workers' Compensation for disbursement.

Additional References

Human Resource Services, Policy Statement 14, Insurance and Retirement Benefits