Advocate – A person who represents the interests of a party to an injury claim, typically an attorney for an insurance company or an employee.
Alternate work / light duty / limited duty / modified duty / transitional work – Temporary work or job tasks that are within an injured worker’s doctor recommended physical restrictions, such as no lifting over 20 pounds or no driving. It is a bridge back to full regular job duties.
Apportionment – The splitting of responsibility between insurers for a claim.
Claim handler – An insurance company employee who oversees an injury claim. Responsible for initial investigation of a reported injury, payment of benefits, review of medical bills and records, and compliance with state regulations.
Dedicated claim handler – A claim handler who is assigned to handle all injury claims for a specific policyholder.
Fraud – Any attempt or action by a person to willingly take or receive benefits of any kind that would not otherwise be rewarded to them.
Gross wages – Total wages earned before taxes are deducted. Multiply total number of hours worked by the hourly pay rate.
Indemnity – Payment of lost wages to an injured employee while they are out of work due to the injury.
Independent medical examination – An appointment with an independent medical provider—one not treating the patient for any reason. Often used as a second opinion.
Loss run – A report of an employer’s claims over policy periods. Typically lists all money spent on each claim as well as claim status.
Lost time claim – Any claim in which the injured worker has been kept out of work past the state-specified waiting period.
Managed care – The process to coordinate medical appointments and follow an injured worker’s progress to an early and safe return to work. A nurse case manager typically oversees this process.
Managed care arrangement – A decision by an employer to participate in a network of occupational medical providers for treatment of their injured workers.
Mediation – A negotiation between different parties with the use of an independent person or party overseeing the discussions.
Medical benefits – Medical treatment for an injured worker, including but not limited to doctor visits, physical therapy and prescriptions.
Medical fee schedule – State-specific rules or guidelines governing the payment of medical bills in a workers’ compensation case.
Nurse case manager – A nurse employed by the insurer or their representative to help oversee the medical aspect of a claim. May include reading reports, scheduling doctor visits and attending appointments.
Return-to-work program – A program put in place by an employer to provide temporary light duty positions to accommodate a worker’s physical limitations as a result of their work injury.
Subrogation – The attempt to hold a third party responsible for a worker’s injury.
Statute of limitations – A period of time after which one is legally unable to proceed with an activity, such as filing a claim or appealing the denial of a claim.
Vocational rehabilitation – A process to help an injured worker find employment within any work restrictions they may have. Most commonly used when work is no longer available at their employer.
Wage replacement benefits – Payments made by the insurer to an injured worker to replace lost wages due to time out of work.
Waiting period – The number of days determined by a state that an injured worker must be out of work before qualifying for indemnity (or wage replacement) benefits.