Tennessee has strict claims handling standards for adjusters and employers to ensure that work-related injuries and illnesses are reported timely and correctly.  Employers covered by the Tennessee Workers’ Compensation Act must submit all known or reported injuries or illnesses to their insurance carriers, unless they are qualified to be a self-insured employer, within one (1) working day of the employer’s knowledge of the injury or illness.  Insurance carriers or self-insured employers must file notice of the injury or illness with the Division through Electronic Data Interchange (EDI) on Tennessee Employer’s First Report of Work Injury or Illness (Form C-20) as soon as possible, but not later than fourteen (14) days after knowledge of the injury or illness.  Additional information on filing may be found on the Electronic Data Interchange (EDI) page.  Reportable workplace injuries or illnesses are those that cause:

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

WHEN AN INJURY IS REPORTED, THE ADJUSTER MUST:

• Make a personal or telephone contact with the employer and the injured employee within two (2) working days of its notice of injury to confirm the facts of the claim, the history of any prior claims, and the injured employee’s work history, wages, and job duties. Insurance carriers and employers must obtain a description of the job and prior claim information of the claimant within five (5) working days.  This may include a recorded statement.
• After obtaining a Medical Waiver and Consent Form (Form C-31) from the employer that is signed by the injured employee, contact physicians who have rendered medical services to a claimant within seventy-two (72) hours to confirm details concerning the injury and treatment and to make a preliminary compensability determination.  All aspects of contacting and attempts to contact employers, injured workers and/or medical providers must be documented and kept within the adjuster’s files.
• Contact all pertinent witnesses as they become known.
• Accept or deny the claim within fifteen (15) days of its knowledge of the injury and file the appropriate form(s) as indicated below.  The insurance carrier must notify the employer and the injured employee of its decision within those fifteen (15) days.

COMPENSABILITY DETERMINATION
Decisions on workers’ compensation insurance coverage and compensability must be made within fifteen (15) days of a verbal or written notice of an accident or injury.  Upon making its determination after a proper investigation the employer, self-insured employer, or adjuster must file, with the Division, the appropriate forms.  Claimants and employers must be notified of the decision of compensability within fifteen (15) days of the notice.

• If an adjuster accepts the claim, and indemnity benefits are paid, a Notice of First Payment of Compensation (Form C-22) must be filed immediately.  Employers, self-insured employers, and/or insurance companies shall file Form C-22 through EDI.
• Immediately upon the change or termination of benefits, adjusters must file Notice of Change or Termination of Compensation Benefits (Form C-26) through EDI.
• If an adjuster denies a claim, a Notice of Denial of Claim For Compensation Form (Form C-23) must be filed with the Division on both paper and through EDI and a copy of that form must be provided to the claimant at the same time. The adjuster must provide documentation which meets the statutory criteria for denial on that form.  The denial of a claim must also be supported with documented results of an investigation.
• A Notice of Controversy (Form C-27) shall be filed in claims only if temporary disability payments have already been started and the employer or adjuster subsequently elects to controvert its liability.

PAYMENT OF BENEFITS
Compensation payments for a compensable work-related injury or illness must be received by the injured employee no later than fifteen (15) calendar days after the notice of injury.    Unpaid or untimely paid benefits may be subject to a penalty.

SETTLEMENT PROCESS
Parties are encouraged to negotiate the final settlement of claims.  A medical impairment rating, a date of maximum medical improvement determined by the treating physician and all other information needed to settle a claim shall be documented in writing in claims involving permanent impairments.  Adjusters shall make an offer of settlement in writing within thirty (30) calendar days of receipt of information specified above.  An agreed settlement shall be finalized by either an order of the court or by approval by a Workers’ Compensation Specialist within the Division.  A copy of the court order or division’s approval shall be filed with the Division.  If settlement is not agreed upon in private negotiations, a Benefit Review Conference may be requested.  Parties are precluded from filing a lawsuit to resolve the matter until the Benefit Review process has been exhausted.

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

IMPORTANT NOTES:

• All workers’ compensation benefits shall be issued timely to assure the injured employees receive the benefits on or before the date they are due.

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.