A claim is filed when an injured worker completes the upper portion of a Claim for Compensation, called a C-4 form. The treating doctor completes the bottom portion of that form and sends it to the employer and to the employer's insurer. The claim is considered filed when the third-party administrator (TPA) for the insurer for the employer actually receives their copy of the C-4 form from the treating doctor. It is the doctor's responsibility to make sure that the C-4 form is completed after asking whether the injury is work-related, and it is the doctor's responsibility to make sure that a copy is sent to the right TPA for your employer.
If a C-4 form is never completed by the injured worker, and it is never received by the TPA, there is no claim yet. It is not enough that an employer knows about a work injury, or that the injured worker gives his employer a written accident report. The injured worker must also complete a C-4 form with a doctor to get a claim started. If the injured worker is unable to complete a C-4 form at the hospital, a staff person at the hospital may do it.
The C-4 Claim form asks the injured worker for a date the injury occurred. The injured worker must not be careless when giving the date of the accident. A claim form must be filed within 90 days of the accident. However, many claims are denied by adjusters because an injured worker did not get medical care and complete a C-4 soon after the accident happened. It is more difficult to show that an injury happened at work when an injured worker waits weeks before going to a doctor.
How the injured worker completes the C-4 form is important. Unless he or she can pinpoint a specific date and time when the injury occurred, and state on the C-4 form how it happened, the claim will probably be denied. It is not sufficient for an injured worker to state on the C-4 form that the injury most likely happened at work without giving definite information on when and how it happened. The injured worker has the burden of proof to show that his injury is work-related.
In addition to asking the injured worker how and when the injury happened, the C-4 form asks what body parts were injured. Adjusters like to deny authorization for treatment to any body parts that are not listed as being injured on the C-4 form. It is possible to add body parts later, but is often difficult and may involve appeals.
The injured worker is also required to give his employer a written accident report, called a C-1 form, or Notice of Injury/Occupational Disease. The law states that the injured worker has 7 days to give a written accident report to the employer, but most employers have company rules that require their employees to immediately notify a supervisor of work accidents. An employer may also require drug testing following an injury, and this needs to be done immediately following an accident. If the employee appears to have purposefully delayed reporting an accident in order to avoid the immediate drug testing, the employer may be justified in firing the employee even if the employee has a legitimate work injury, and even if the worker's compensation claim of the employee is accepted.
If the injured worker does not file a C-4 form within 90 days of the date of his accident and injury, the claim will almost always be denied by the insurer. There is an excuse provision in the law that allows hearings and appeals officers to allow the late claim filing for good reasons, but hearings and appeals officers in southern Nevada do not excuse many late claims. An injured worker may not realize the severity of an injury right after the accident and therefore delay in seeing a doctor, but a delay of more than 90 days is very risky, particularly if a surgery is necessary.
Some injured workers purposefully do not file a C-4 Claim form after a job accident, thinking that they may have trouble at work if they do. However, if the injured worker has asked their chiropractor or physician not to file a C-4 form, and a private medical insurer is billed, it will be very difficult to file a claim later.
The adjuster has 30 days after receiving the C-4 Claim for to either accept or deny the claim. If the claim is denied, the injured worker has only 70 days to file a request for hearing with the Department of Administration hearings division on the form provided with the denial letter. The injured worker must attend the hearing in person, or by telephone, if a phone hearing is pre-arranged, unless the injured worker is represented by an attorney at the hearing. The free legal services of the Nevada Attorney for Injured Workers (NAIW) are not available at this level of hearings.