Employers covered by the Tennessee Workers’ Compensation Act must immediately submit all known or reported injuries or illnesses to their insurance carriers unless the employer is qualified and certified as a self-insured employer. To learn which employers are covered by the Act, please click here.  Self-insured employers must either report the claim to their Third Party Administrator (TPA) or internal claims handling program.  Reportable workplace injuries or illnesses are those that cause:

• An employee to receive medical treatment outside of the employer’s premises;
• Their absence from work, or their retention of a permanent impairment; or,
• Their death.

WHEN AN EMPLOYEE CLAIMS TO BE AT INJURED WORK, THE EMPLOYER MUST:

• Fill out a First Report of Injury (Form C-20) and file the form with its insurance adjuster within one (1) working day of its knowledge of the injury.  The claim must be reported to the adjuster even if the employer feels the claim is not work-related.  The insurance adjuster can investigate and deny the claim, if appropriate.
• Provide the injured employee a panel of at least three (3) physicians, within the community of the injured employee’s home or workplace and not in the same practice, on an Agreement Between Employer/Employee Choice of Physician Form (Form C-42).  If the employer does not have a panel of physicians available at the time the injury is reported, it should immediately call its insurer and develop one.

• If the injury is to the back, the panel must be expanded to four (4) medical providers and must include a chiropractor.
• If specialized medical treatment is required, the authorized treating physician may refer the employee for such specialized treatment at which time another panel of specialized physicians should be offered.
• Have the employee:
  • Select a physician from the panel; and
  • Sign the form.
• In the event the insurer, employer, or self-insured pool or trust knowingly and intentionally fails to timely file the wage statement, the Division may deem the employee’s compensation rate to be the maximum workers’ compensation rate effective on the date of injury.

The employer should keep the original form and provide a copy to the employee.  The employer must provide a copy to the Division of Workers’ Compensation upon request.  This selected physician becomes the “authorized treating physician.”

• Have the injured employee sign a Medical Waiver and Consent Form (Form C-31).  This form allows the employer, insurance carrier, third party administrator, case manager, utilization review agent and the Division communicate with the treating physician about the treatment for the injury.
• Assist the employee and/or the insurance adjuster in scheduling the initial appointment and in authorizing medical treatment.
• Inform the employee of the name and telephone number of the employer’s workers’ compensation insurance carrier and adjuster.
• Submit a statement of the employee’s wages to their workers’ compensation insurance adjuster on a Wage Statement (Form C-41).  The wage statement should show the gross wages earned by the injured employee, including overtime, bonuses, etc., each week for the fifty-two (52) weeks prior to the injury.  If the injured employee has worked for the employer for less than 52 weeks, the statement should show all of the weeks worked and gross wages earned each week.

For additional information about this topic, please call the Tennessee Department of Labor at  615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES:

• The list of physicians must be provided on the Agreement Between Employer/Employee Choice of Physician Form (Form C-42) (*Click here for Spanish version).  Alternative versions of the form are not allowed.
• The C-42 form designating the chosen physician and signed by the employee is the employer’s proof that the employee was offered a choice of physicians.  It must be signed by the employee and dated, indicating the date the physician was selected.
• The injured employee’s wages must be provided on the Wage Statement (Form C-41).  Alternative versions of the form are not allowed.
• Failure to provide a completed Wage Statement to the insurance adjuster could place the employer at risk for being ordered to pay temporary disability benefits to the injured employee at the maximum weekly benefit, which may be an amount higher than would otherwise be due.  That amount can be adjusted by filing a corrected Wage Statement (C41); however, the employer will not receive a credit on future benefits to cover the overpayment.

 

PLEASE NOTE: THIS INFORMATION IS PROVIDED BY THE TENNESSEE DEPARTMENT OF LABOR AND IS INSERTED HERE ONLY AS A MATTER OF CONVENIENCE.  THE ORIGINAL INFORMATION CAN BE FOUND HERE.