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POLICYHOLDER CENTER

Workers’ Compensation

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Valued ICW Group Policyholder
Melissa Takeda
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CLAIM FAQS


FREQUENTLY ASKED QUESTIONS ABOUT CLAIMS

We hope you find these FAQs helpful. If you can’t find the FAQ you need and
still have questions, please call us at 800.877.1111.

Jump to:

New Claims – Medical – Lost Time – Suspected Fraud – Human Resource – Legal –
Reserves




NEW CLAIMS

I just reported a claim – what happens next?

Once you’ve initiated a workers’ compensation claim with us, you’ll be contacted
by your Claims Examiner for additional details within 2 business days after we
receive your claim. If you have a California or Illinois claim with lost time,
an examiner from our specialized Triage Unit will be assigned to assist.

Learn more about the Claims Process in From First Report to Return to Work and
our Specialized Claims Triage Team.



How do I find out who my Claims Examiner is?
Your Claims Examiner will contact you within 2 business days after we receive
your claim. At this time, they’ll provide you their name and contact
information. Within one week of reporting your claim, you may find your Claims
Examiner information online by reviewing your Loss Run Reports and Claim Summary
Reports in myResource.



What is covered by workers’ compensation insurance?

Workers’ compensation provides benefits to employees who get injured or sick
from work-related causes. It includes reasonable and necessary medical treatment
and related costs, and temporary/permanent disability benefits, missed wage
replacement and survivor/dependent death benefits. This may include vocational
rehabilitation benefits, depending on jurisdictional requirements.



How do I gain access to my loss runs and claims reports online?

Both loss runs and claims summary reports are available in ICW Group’s
myResource system.

If you don’t yet have an account, apply for one today using Request a myResource
Account. Please note, you must be provided permission by an Owner or Officer of
your Company to access these reports.



This claim isn’t for our employee, so why does it appear under my policy?
By law, we’re required to set up a claim whenever one is reported – even if the
person isn’t your employee. Rest assured our claims team will conduct a thorough
review to determine the circumstance, possible coverage and liability.



A person working for us through a temp agency was hurt. Do we need to file a
claim?
Generally, the answer is no, but if you receive any legal paperwork listing you
as the employer involving an injured employee from a temp agency, you should
immediately report this to ICW Group so that we may set up a file and conduct an
investigation.



My employee was injured at work, what do I do?

When your employee is injured, first make sure they get the medical treatment
they need. Call 911 for any emergency situation.
Based on the nature and severity of the injury, we suggest you decide if an
urgent care clinic is appropriate. In some instances, the nearest urgent care
option may be the emergency room. After providing your employee with medical
treatment options and facility information, report the injury to ICW Group.
You can find step-by-step information and forms on our Report a Claim page.



Do I need to report a non-work related COVID-19 positive test for an employee?

As of 1/1/24, compensability presumptions under Senate Bill 1159 have been
repealed which includes the COVID-19 outbreak calculation. Therefore, employers
no longer need to report non-work related COVID-19 positive tests, however
employers should consider maintaining consistent policies re keeping a copy of
COVID-19 tests in their employees’ personnel files.






MEDICAL

I received (or my employee received) bills related to this claim. Where do we
send them?

For all medical treatment related bills, send to ICW Group, P.O. Box 2965,
Clinton, IA 52733-2965.

For other claim related bills or reimbursement requests, send to ICW Group, PO
Box 509039 San Diego CA, 92150-9039. Or, you may fax these to 858.350.2755.



Do I have the option to pay the medical bills myself, and not report the injury
to ICW Group?

No. All work-related injuries with medical treatment must be reported to ICW
Group. If you, or your employee receive a medical bill related to a work injury,
please forward it to ICW Group for payment consideration.

For all medical treatment related bills, please send to ICW Group, P.O. Box
2965, Clinton, IA 52733-2965.



What is a Panel Qualified Medical Evaluator/Evaluation (PQME)?
This is a California State specific process, where an independent doctor is
selected from a panel of 3 physicians (provided by the State), to help move the
case towards resolution. A PQME may address compensability, nature and extent of
the employee’s injuries and duration of their medical treatment. The PQME may
also help determine the level of the employee’s permanent disability and their
ability to return to work.



Does my state have a panel of physicians?
It depends on the jurisdiction of your claim. Some states do have specific laws
concerning physician panels. That said, all states have their own rules
regarding physician access options. Please contact your examiner at
800.877.1111.



Can we add a doctor to the panel that we’ve used in the past?
It depends on a number of factors. Please contact your examiner to discuss your
options. If you don’t have their direct number, simply call 800.877.1111.



My employee is seeing his personal doctor for the work injury. Is that okay?
Workers’ compensation medical treatment rules vary by state. Some states allow
the employer/insurer to direct care and others allow the employee to choose the
physician. Your Claims Examiner can provide you additional information
concerning your own state’s medical treatment guidelines.



If you need further assistance regarding your claim, please contact your
examiner at 800.877.1111.



My employee was provided a referral for medical treatment and/or diagnostic
tests. Is there anything we need to do?
Usually, there is nothing you need to do. The doctor’s office should have
submitted this referral to your Claims Examiner. However, you may fax or email
the referral to your Claims Examiner if you need further assistance.



Our employee is not following the work restrictions outlined by the physician.
What can we do?
We encourage you to talk to your employee so they understand they’re required to
work within the restrictions outlined by their treating physician. This will
help them avoid re-injury or worsen their condition.



For further assistance on this situation, please contact your examiner at
800.877.1111.



What are our options when we disagree with the treatment plan for our employee?
We encourage you to communicate with your Claims Examiners if you disagree with
the direction of medical care. Each state may have its own rules regarding
treatment disputes.



Why are we paying for medical treatment related to pre-existing conditions?
As an employer, you may be liable for treatment related to pre-existing
conditions if the work injury aggravated, exacerbated or accelerated the
condition.








LOST TIME

How do we get our employee back to work?
Be sure to inform your Claims Examiner if you’re able to accommodate modified
duty. They’ll convey this information to the doctor and inquire if the employee
is able to perform work with modified restrictions. Your Claims Examiner can
help walk you through this process to get the best possible outcome.



To understand more about Return to Work programs and what you can do, see The
Road Back to Work: Building a Successful Return to Work Program.



Why is the wage statement needed?
For any injury resulting in lost time or permanent partial disability,
regardless of whether your employee has returned to work, we may be required by
law to obtain historical wage statements for up to 1 year from date of injury.
This wage statement allows us to confirm your employee’s compensation rate and
determine the regulated benefit rates for their jurisdiction.



How soon will my employee get paid wage loss benefits?
As a general rule and depending on the claim jurisdiction, benefits are issued
approximately 14 days from the date the employer/claims administrator has
knowledge of the disability.



Why should we offer light duty in writing when the injured worker already agreed
verbally?

If your employee declines the offer or does not show up for work, you’ll have
written documentation of a good faith offer of work as well as documentation
showing that the employee had knowledge of the offer. The workers’ compensation
benefits owed to the injured employee may be impacted.

To help, we offer several references in our The Road Back to Work: Building a
Successful Return to Work Program.



Is my injured employee’s claim eligible for settlement?
It depends – there are a number of factors that determine whether a workers’
compensation claim is eligible for settlement. Since this could vary by
jurisdiction, it’s best to contact your ICW Group Claims Examiner with questions
regarding settlement.



My employee has permanent restrictions caused by their injury. Am I required to
take them back and what is the process for addressing this?

Making permanent accommodations for an injured employee’s work restrictions is
considered an employment action. To help you with these types of Human Resource
questions, ICW Group provides HR OnDemand® – included free with your policy. Use
this service to gain expert HR advice via phone, email or online.

For more information on this helpful service, visit our HR OnDemand page.



Why can’t we stop benefits after an injured worker has been terminated from
employment?
By law, terminating an employee doesn’t end our responsibility to continue
workers’ compensation benefits to which they are entitled.



What is Permanent Disability and why is our employee getting paid Permanent
Disability while working full duty?
Permanent Disability or Permanent Impairment is a statutory workers’
compensation benefit that employees are entitled to receive in many states.
Benefits typically start at the time of maximum medical improvement or when the
employee is released from their physician’s care. These benefits are owed to the
employee even if they return to work in any capacity.



The physician has provided a release for my employee to return to full duty
work, so why is medical treatment continuing?
Often, a physician will not indicate an employee has achieved “maximum medical
improvement” (MMI) until the employee has demonstrated their ability to perform
full duty work for several days or weeks, depending on the nature of the work.
Until then, we’re required to provide reasonable and necessary medical care.



Why can’t my claim settle or close now?
Our top priority is to ensure your employee has reached the end of the healing
period. We make every effort to settle or close every workers’ compensation
claim as quickly as possible. If you have any questions or wish to discuss this
further, please contact your Claims Examiner.



Could you help me better understand the length of time my employee’s claim has
been open?

There’s no set length of time for a workers’ compensation claim. The duration
depends on the complexity of the issues surrounding it, the resolution strategy
and jurisdiction.

Some claims involve simple injuries that require minimal treatment, if any, and
may be closed as soon as medical payments are issued. Others may be more complex
and involve serious injuries with extensive medical treatment needs, vocational
rehabilitation, subrogation, hearings, third-party actions, death, fraud, etc.

For most cases, a workers’ compensation claim is never really “closed” as there
are various applicable statutes of limitations laws, depending on jurisdiction.
For example, a case may reopen if the work injury or condition worsens. Some
cases conclude when the injured worker accepts a full and final settlement offer
designed to settle all remaining issues, and or current and future claim
benefits.



How will I know when a claim closes?
You can quickly learn the status of the claim by referring to your online loss
run reports, accessed through ICW Group’s myResource. If you have questions
about accessing loss run reports, Loss-Runscontact WC Loss Runs.








SUSPECTED CLAIM FRAUD

What if I suspect a claim is fraudulent?

First, express your concerns with your Claims Examiner – they can help answer
any questions. After you speak with your examiner, you can also call the ICW
Group’s Fraud Unit, 800.877.1111. They’re experts in this area and are available
to help answer any questions or concerns you may have regarding suspected fraud.

For helpful Fraud resources and tools, see the Fighting Fraud page. Be sure to
download the R.E.P.O.R.T. Worksheet to help guide your Investigation and view
the 10 Ways You Can Prevent Fraudulent Claims for additional advice.



Does ICW Group review my claims for fraud?

Yes. EVERY claim processed is automatically reviewed for fraud within 24 hours
and vetted using 3,000 data points. Also, all claims are automatically checked
for signs of fraud multiple times throughout the life of the claim.

See The 8 Ways We’re Extra Tough on Fraud for additional information.



If I suspect fraud, can we do our own surveillance?
We can do this for you! Surveillance is a useful tool which is commonly used by
ICW Group to investigate suspicious claims. While inhouse security systems are
very helpful, we discourage customers from conducting outside surveillance or
using private investigator firms, as there may be legal implications.



Why doesn’t ICW Group do surveillance on every claim?
By law, we must be able to demonstrate reasonable suspicion of fraud prior to
conducting any surveillance. However, most claims are valid and therefore,
surveillance is not appropriate nor legally allowed on every claim.



What is the difference between red flags, suspected fraud and fraud?

Red flags simply means there are suspicious actions that may necessitate further
investigation. Suspected fraud occurs when we feel we’ve identified a
deliberate, provable claim misrepresentation, which allows us to submit the
claim to law enforcement for a criminal investigation. The final verdict of
whether a claim is fraud is decided by the court.

See the Top Ten Red Flags of Work Comp Fraud for additional information.



Why are we paying wage loss benefits and providing medical treatment when the
claim is questionable?

The requirement to pay wage loss benefits and provide medical treatment varies
depending on jurisdiction. In many jurisdictions, we’re required to continue
benefits until clear and convincing evidence can be gathered to defend against
the claim(s) being made. ICW Group partners with you in the investigation of
questionable claims, gathering any available evidence which may assist in the
proper defense of the claim.

For helpful Fraud resources and tools, see the Fighting Fraud page.








HUMAN RESOURCE RELATED

My employee has questions about their claim, how can I help?
Your Claims Examiner will be happy to assist with answering all of your
employee’s questions. Simply contact us – we’re happy to help!



Can I contact my injured employee to see how they’re doing?

Yes! In fact, staying connected with your employee after an injury shows
compassion, fosters a trustful relationship and can help minimize claim costs.

To easily send thoughtful messages and provide helpful materials, see our “On
the Road to Recovery” Ecards, available in both English and Spanish.



How are Employee Health Care premium payment handled while they’re out of work?

Of course, injured workers on workers’ compensation have all their related
medical treatments covered. However, your employee’s health insurance is
separate from workers’ compensation and are not covered as part of the benefits.
Thus, these premium payments still need to be made to continue that coverage.
How this is handled is an employment decision. To help you with these types of
Human Resource questions, ICW Group provides HR OnDemand® – included free with
your policy. Use this service to gain expert HR advice via phone, email or
online.

For more information on this helpful service, visit our HR OnDemand page.



Our employee had pre-planned vacation before they were injured – what happens
now?
Depending on the claim jurisdiction, an employee who accrues sick leave and
vacation may be permitted to use the accrued time to supplement temporary
disability payments. Please contact your examiner to learn more.



Is there a resource for learning the details on the rules about keeping a job
open for someone who has been hurt at work?

Yes! ICW Group offers HR OnDemand as a free service to all our current
policyholders for assistance with employment related questions. You can call
them between the hours of 8am to 7pm Central Time, Monday through Friday at
1-855-473-6782.

For more information on this helpful service, visit our HR OnDemand page.

Alternatively, you may want to contact an employment attorney.



Can we learn more about terminating someone who has a workers’ compensation
claim?

ICW Group offers HR OnDemand as a free service to all our current policyholders
for assistance with employment related questions. You can call them between the
hours of 8am to 7pm Central Time, Monday through Friday at 1-855-473-6782.

For more information on this helpful service, visit our HR OnDemand page.

Alternatively, you may want to contact an employment attorney.



Can I get a list of my claims, reserves, and status?

Yes! Simply access your Claim Summary Reports and Loss Reports using myResource.
Please note, you must be provided permission by an Owner or Officer of your
Company to access this confidential information.

Need a myResource Account? See Request a myResource Account.



Can I get an updated loss run?

Of course! Quickly access your Loss run and Claim Summary Reports using
myResource. If you have questions about loss runs, Loss-Runscontact the Service
Center of Excellence. Please note, you must be provided permission by an Owner
or Officer of your Company to access this confidential information.

Need a myResource Account? See Request a myResource Account.



Can ICW Group use our departmental / location codes in your claims system and
loss runs?
Yes! Since this involves policy coordination, please contact your Agent/Broker
so they may work with the assigned Underwriter in making this possible for you.



Do I need to report a non-work related COVID-19 positive test for an employee?
As of 1/1/24, compensability presumptions under Senate Bill 1159 have been
repealed which includes the COVID-19 outbreak calculation. Therefore, employers
no longer need to report non-work related COVID-19 positive tests. However,
employers should consider maintaining consistent policies with regards to
keeping a copy of COVID-19 tests in their employees’ personnel files.








LEGAL

If an employee is injured traveling to or from work, can they receive workers’
compensation benefits?
Usually, no. However, there are exceptions. Please contact your Claims Examiner
to discuss the specific details of the claim.



If an employee is terminated due to an invalid social security card and they
have an accepted claim, are they still entitled to workers’ compensation
benefits?
Yes. An invalid social security number does not preclude an employee’s right to
claim workers’ compensation benefits. Please contact your claims examiner
immediately to advise them of this termination.



What do I do if my employee is represented by an attorney?
Please contact your Claims Examiner as soon as you know. They’ll guide you
through the process.



I received legal documents for an employee’s claim; who do I contact?
In the event you receive legal documents concerning your employee’s claim,
contact your Claims Examiner for assistance. They’ll request you to fax, mail or
email the documents for their review.



Do we need to attend legal hearings?
Generally, no. You don’t have to attend unless you’re served with a subpoena –
then your attendance may be required. We recommend you discuss this with your
Claims Examiner.



I received a subpoena. What do I do?
The subpoena for records requires the custodian of records (the person or entity
responsible for keeping records in the ordinary course of business) to produce
the records to the requesting party by a specific date, no less than 10 days
after the date of service of the subpoena. ICW Group is not the custodian of
records for the personnel file or other business records held by an employer.
Because of this, ICW Group cannot produce them or provide legal advice on which
records should be produced. You should consult with your human resources
manager, general counsel, or employment attorney for this advice.



Why are we settling a denied claim?
Depending on the facts of the claim, including risks of potential outcomes,
settling a denied claim could be the best course of action.



What is subrogation?
Subrogation refers to the legal process that provides the right for a workers’
compensation carrier to pursue recovery of benefits paid on a claim from a
responsible third party.



Is the claim reimbursed 100% if there is a third party at fault?
It depends. The amount of recovery is determined by many factors, including an
assessment of the responsibility of all parties for causing the accident, the
likelihood of recovery from the responsible parties, and the costs of
litigation.  Our goal is to achieve the best possible results given all of the
relevant factors.






RESERVES

The claim reserves seem high. Can it be reduced?
It depends. There are a number of different factors that influence how a claim
is reserved. Your Claims Examiner can assist you with understanding the details
of the reserve.



How can I help control the cost of a workers’ compensation claim?
As an employer, there are several steps you can take to help control the cost of
a claim:



 * Report the incident as soon as possible.
 * Set aside any evidence such as machinery, equipment or other item(s) that may
   have been involved in the accident.
 * Provide your Claims Examiner with all relevant information, including witness
   information, video if available, diagram(s) or photo(s) of accident site,
   incident reports, and details concerning any equipment/machinery that may
   have been involved.
 * Provide any medical information you may have at the time of reporting the
   injury.
 * Make every effort to accommodate medical work restriction(s).
 * Maintain positive contact with your employee at regular intervals.



Can the Temporary Total Disability (TTD) reserves be reduced the day that the
employee returns to work?
It depends. There are a number of different factors that influence how a claim
is reserved. It’s best to reach out to your Claims Examiner to discuss the
timing of reserve changes.



How will I know that the reserves changed on a claim?
You can quickly learn the status of reserves by referring to your online loss
run reports, accessed through ICW Group’s myResource. You may also attain a loss
run by Loss-Runscontacting WC Loss Runs and requesting this report. You must be
an owner, principle or authorized user to receive a copy of the loss run.



What will this reserve change mean to my rates?
Your insurance agency would be the best resource to assist you with questions
about your rates and the calculation of your experience modification.





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