The Claims Process

Claims Initiation

When the First Report of Injury (WCC Form 12-A) is received, it is recorded and the information placed in our computer system. The claim is assigned a 9 or 10 digit State Accident Fund Claim Number. This unique number is the primary means of identifying this claim and should be included in all correspondence. If all required information has been received, the system will set the initial reserves for the claim. The reserves are an estimate of the total claim cost. The computer also generates two letters acknowledging receipt of the claim. One letter is sent to the claimant, and the other to the employer.

Determining Compensability

If the claim involves a death, heart attack, mental stress, or other psychological disorder, it is sent directly to the investigations branch. The investigations branch will gather the necessary information to recommend acceptance or denial of the claim, depending on the circumstances. In all other cases, the claim is sent to the assigned adjuster, who is responsible for reviewing the report, gathering any additional information required, and determining compensability (if the claim is payable under SC workers' compensation law.) If the adjuster determines the claim is not compensable, he/she will bring the claim to the Claims Review Team. The Claims Review Team will either uphold the recommended denial, overrule it, or request additional information prior to making a decision. When it is determined that the claim is accepted or denied, a letter will be sent to the employer, the claimant, and the Workers' Compensation Commission (if required), informing them of the decision. If the claim is denied, the letter will state the reason for denial.

Thirt Party Liability and Subrogation

If an injury is the result of an automobile accident, possible product liability, or negligence on the part of a third party, an option letter will be sent to the claimant. The claimant must complete the option letter and return it to the State Accident Fund. We can not pay any benefits prior to the return of the option letter. If the employee elects to settle their claim with the third party and not pursue a workers' compensation claim (option 1), the claim is closed. If he/she pursues a workers' compensation claim (option 2 or 3), the adjuster manages the claim in the same manner as any other claim. Recovery from the third party (subrogation) is pursued through legal channels one the claim in concluded. This can be a very time-consuming process. Any funds recovered are credited back to the claim, directly reducing your claim costs.

Payment of Medical Bills

Under SC workers' compensation law, an injured worker is entitled to reasonable medical care for the duration of his/her injury, until such time that "maximum medical improvement" (MMI) has been reached, as determined by the authorized treating physician. South Carolina law allows the employer/insurance carrier to designate a physician. Employers are encouraged to establish a designated physician program to develop a working relationship with a physician who specializes in occupational medicine. This physician should be the first source of evaluation, treatment, and/or referral anytime an employee is injured. An ongoing relationship such as this reduces medical costs and time lost from work. The use of a designated physician should be included in any written personnel policy covering the reporting of on-the-job injuries and communicated to all employees. To assist in reducing medical costs, the State Accident Fund is conducting a pilot program utilizing three "managed care" companies. Trained nurses review medical findings and work with medical providers to ensure injured workers receive appropriate, high quality medical care to speed healing and reduce disabilities. Injured employees receiving medical benefits under workers' compensation should always give the medical provider the State Accident Fund claim number (the SF number contained on the letter) to be included on all bills. This will expedite the processing and payment of these bills. If the medical provider sends bills to the employer or the employee, the bills should be forwarded to the State Accident Fund (remember to include the SF claim number.). The adjuster reviews all medical bills and reports. If the injury is compensable, the adjuster will approve medical bills for authorized treatment and send them to our Accounting Division for processing and payment. If medical bills are denied, the adjuster will return them to the medical provider, with an explanation of why they were not accepted.

Payment of Compensation for Lost Time

The employer must notify the State Accident Fund if the claimant is unable to work due to the injury. Based on the medical documentation submitted by the authorized treating physician and the attendance information provided by the employer, the adjuster will determine if the claimant is eligible for lost time disability compensation. If an employee is out-of-work less than seven days, they are not eligible for temporary total disability payments. If the employee is out of work more than seven, but less than fourteen days, they are eligible to for lost time benefits beginning on the eighth day. Once they have been out of work for more than fourteen days, they are eligible for benefits retroactive to the first day they were unable to work. Once eligibility has been determined, the adjuster will determine the amount of lost time and the rate of payment. If the employee is totally unable to work, their compensation rate will be two thirds (.667) of their average weekly wage, up to a maximum amount set by law. The adjuster will complete the first section of a WCC Form 15 (Temporary Compensation Report - See Figure 3-4.) At the same time, a request for payment is forwarded to the Accounting Department. A voucher is prepared and submitted to the SC Comptroller General's Office. The State Treasurer's Office then generates the check and returns it to SAF. SAF then sends the check to the claimant. In the near future, all paperwork will be managed internally and checks will be generated directly by SAF. The check and the WCC Form 15 are then sent to the claimant. The WCC Form 15 explains what the compensation rate is and the period covered by the check. If the employee is represented by an attorney, these items are sent directly to the claimant's legal representative.

If the nature of the employee's injury indicates a prolonged absence from work, the adjuster will establish a running award (automatic generation of weekly benefit checks, payable directly to the claimant).

Stopping Compensation

When an employee who is on a running award is no longer entitled to compensation either because they have returned to work or any of the other reasons stated in section two of the WCC Form 15, the adjuster must be notified immediately. Prompt notification will minimize any overpayment of compensation and possible financial hardship for the employee. If it has been less than 150 days since the employer received notice of the injury, the adjuster will prepare another WCC Form 15, to include Section 2, "Termination of Temporary Compensation" and mail it to the claimant or their attorney. If the claimant or their attorney disagrees with the decision to stop benefits, they may request a hearing with the SC WCC by completing Section 3, "Notice to Injured Worker or Legal Representative When Temporary Compensation Has Been Stopped" and sending a copy to the SC WCC. Section 3 should NOT be signed and returned unless a hearing is requested. If compensation for lost time is terminated 150 days or more after the date the employer was notified of the accident, the adjuster must prepare the WCC Form 17 (Receipt for Compensation.) They will forward this to the employee or their legal representative for signature, as required by law. If the employee or their legal representative fails to sign and return this form, the State Accident Fund will file a WCC Form 21 with the Workers' Compensation Commission requesting a hearing be set to stop payment of temporary total or temporary partial benefits.

The Claims Settlement Process

When the employee has recovered from his/her injury, the medical provider will send a letter to the State Accident Fund stating that "Maximum Medical Improvement" (MMI) has been reached. Included in this letter will be an impairment rating. The adjuster will evaluate the case and prepare a settlement. The adjuster will base his/her offer on their knowledge of the claim. They will determine, in accordance with established guidelines, the degree of disability or disfigurement if appropriate. Claims involving disability or disfigurement may be settled using a WCC Form 16 (Agreement for Permanent Disability/Disfigurement Compensation), an Order issued by the Workers' Compensation Commission as a result of a formal hearing, or an Agreement and Final Release (Clincher). Claims settled on a WCC Form 16 or by an Order may be reopened within one year from the date of the last compensation payment if the injured worker undergoes an adverse change of condition. An Agreement and Final Release (Clincher) relieves the employer and insurance carrier from any further responsibility for payment of compensation or medical expenses, unless the Clincher Agreement specifically provides otherwise. If the claimant is represented by an attorney, the adjuster will prepare the appropriate document and forward it to the legal counsel for the appropriate signatures. It is then sent to the Workers' Compensation Commission for approval. Upon receipt of the approved documents, the compensation is paid and the claim is closed. If the claimant does not have legal representation, SAF requests the scheduling of an Informal Conference with the Workers' Compensation Commission. An informal conference involving a Form 16 settlement may be conducted by a commissioner or claims mediator. The commissioner or claims mediator will review the claim and make an award. The claimant and the insurance carrier may accept or decline the settlement award. If both parties accept the award, a WCC Form 16 is executed by the claimant and a SAF representative. It is then approved by the Commission. The adjuster prepares a check and a WCC Form 19 (Status Report and Compensation Receipt.) If the injured worker is still with the same employer, the check, Form 19, and detailed instructions may be sent to the employer representative. If either party decline the offer, the Workers' Compensation Commission will set the case for a hearing. If a Clincher settlement is reached with a claimant who is not represented by an attorney, a Clincher Conference will be conducted by a commissioner. The commissioner reviews the settlement to insure it is fair and reasonable. Hearings are scheduled at the request of the claimant, their legal counsel, and/or the insurance carrier. A claimant or their legal counsel requests a hearing by filing a WCC Form 50 or Form 52 with the SC WCC. If the State Accident Fund requests a hearing to stop payment of temporary compensation (or in some cases, to pay for permanent disability), they file a WCC Form 21. When a claim is scheduled for a hearing, an attorney is assigned to the case to prepare it for litigation and to represent the State Accident Fund at the hearing. SAF sometimes uses outside contract attorneys to supplement in-house legal counsel. When a request for a hearing is filed, the Workers' Compensation Commission contacts the State Accident Fund and requests a WCC Form 20 (Statement of Earnings of Injured Employee).

Preparing the WCC Form 20

The WCC Form 20 verifies the claimant's earnings (Average Weekly Wage) during the last twelve months prior to the accident. Compensation is based on this amount. Without a WCC Form 20, the Workers' Compensation Commission may set the compensation rate up to the maximum amount allow by law. If a hearing has been requested, a WCC Form 20 must be submitted to the Workers' Compensation Commission within 30 days of the request for a hearing. The State Accident Fund will contact the employer for the required information. If the claimant receives temporary compensation, the form must be completed within 30 days and SAF must supply a copy to the claimant. (To minimize rework and to ensure compliance with the regulation, it is recommended that employer claims representatives submit a WCC Form 20 with the Employers First Report of Injury or Illness on all claims which they feel will result in disability, scarring, or payment of temporary total benefits. Please contact your adjuster for additional information.) When preparing the WCC Form 20, follow the instructions provided on the form. Quarterly wage information needed on the WCC Form 20 is in the same format as that already reported by your organization to the SC Employment Security Commission. A copy of their form (SC ESC Employer Contribution Report) should be available in your payroll or accounting department.

Log In
Forgot Username?
Forgot Password?

Clicking login indicates you have read and agreed to our Terms and Conditions

Home  |   Accessibility  |   Contact Us