Glossary

A

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 – 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.

C

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.

D

Dedicated claim handler – A claim handler who is assigned to handle all injury claims for a specific policyholder.

F

Fraud – Any attempt or action by a person to willingly take or receive benefits of any kind that would not otherwise be awarded to them.

G

Gross wages – Total wages earned before taxes are deducted. Multiply total number of hours worked by the hourly pay rate.

I

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.

L

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.

M

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.

N

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.

R

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.

S

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.

V

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.

W

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.