FIRST REPORT OF WORK INJURY, FORM C20
Employers covered by the Tennessee Workers’ Compensation Act must submit all known or reported injuries or illnesses to their insurance carriers on Tennessee Employer’s First Report of Work Injury or Illness (Form C-20) within one (1) working day of knowledge of the injury or illness. Insurance carriers and self-insured employers must file the Form C-20 with the Division through Electronic Data Interchange (EDI) as soon as possible, but not later than fourteen (14) days after knowledge of the injury or illness.
A workplace injury or illness that causes an employee to receive medical treatment outside of the employer’s premises, their death, their absence from work, or their retention of a permanent impairment must be reported.
OSHA REQUIREMENTS: The "Tennessee First Report of Work Injury" (First Report) is an allowable substitute for the Occupational Safety and Health Administration (OSHA) 301 form "Injury and Illness Incident Report". OSHA requires employers to maintain a copy of either the First Report or the OSHA 301 on site and available to Tennessee Occupational Safety and Health Administration (TOSHA) representatives.
WHEN AN EMPLOYEE IS INJURED, THE EMPLOYER SHOULD:
- Fill out a Form C-20, as described above, and file the form with its insurer within one (1) working day of knowledge of injury. The claim must be reported to the insurer even if the employer feels the claim is not work-related. The insurance carrier can investigate and deny the claim if appropriate.
Provide the injured employee a panel of at least three physicians on Agreement Between Employer/Employee Choice of Physician Form (Form C-42). If the injury is to the back, the panel must include a chiropractor. If specialized treatment is required, the authorized treating physician may refer the employee for such specialized treatment at which time another panel of specialized physicians should be offered. The named-providers should be located in or near the employee's community of residence. The employee has the privilege of choosing one physician from the list. This selected physician becomes the “treating physician.” A Form C-42 designating the chosen physician and signed by the employee is the employer's proof that the employee was offered a choice of physicians. A copy of this completed form must be provided to the employee. The employer must keep the original form on file and provide a copy to the Division of Workers' Compensation upon request.
If the employer does not have a panel of physicians, it should call its insurer and develop one. The employer should post the panel of physicians in a conspicuous place for employees to review.Have the injured employee sign a Medical Waiver and Consent Form (Form C-31). This form allows the employer, insurance carrier, third party administrator, case manager, utilization review agent and Division to communicate with the treating physician about the treatment for the injury.
Inform the employee of the name and telephone number of the employer’s workers’ compensation insurance carrier/adjuster.
Submit a statement of the employee's wages to their workers’ compensation insurer. The statement should show the gross wages earned by the injured employee each week for the fifty-two (52) weeks prior to the injury. If the injured employee was employed less than 52 weeks, the statement should show all of the weeks worked and gross wages earned each week, including overtime, bonuses, etc.
WHEN AN INJURY OCCURS THE INSURER MUST:
- Make a personal or telephone contact with the employer and the injured employee within two (2) working days of its notice of injury.
Accept or deny the claim within fifteen (15) days of its knowledge of the injury. The insurance carrier must notify the employer and the claimant of its decision within those fifteen (15) days.
For accepted claims, issue compensation payments to the claimant, if required. All required workers' compensation benefits must be issued timely (on or before due date). File all appropriate claims forms as required by the Tennessee Department of Labor and Workforce Development, Division of Workers' Compensation. Additional information on filing may be found under Electronic Date Interchange (EDI).
For denied claims, timely file all appropriate claims forms as required by the Tennessee Department of Labor and Workforce Development, Division of Workers' Compensation.
CLAIMS HANDLING STANDARDS OVERVIEW
Claims handling standards may be found in the Rules of the Tennessee Department of Labor and Workforce Development, Division of Workers' Compensation, Chapter 0800-02-14. Those Rules can be obtained from the Secretary of State's Web page athttp://www.tn.gov/sos/rules/0800/0800-02/0800-02.htm. The purpose of the claims handling standards is to assure that employees sustaining an injury arising out of and in the scope of employment are treated fairly and to assure that workers' compensation claims are handled in an appropriate and uniform manner. The provisions apply to all employers in the State of Tennessee covered by the Tennessee Workers’ Compensation Act and to all insurers processing Tennessee workers’ compensation claims.
REQUIRED CONTACTS
All aspects of contacting and attempts to contact employers, claimants and/or physicians must be documented and kept within the insurer’s file. The insurer must:
- Upon the verbal or written notice of any injury from an employer, make verbal or written contact with the claimant within two (2) working days to confirm facts of the claim, history of prior claims, work history, wages, and job duties. This may include a recorded statement.
Make personal or telephone contact with the employer within two (2) working days of the notice of the injury to verify details of the claim. Insurance carriers and employers must obtain a description of the job and prior claim information of the claimant within five (5) working days.
Contact all pertinent witnesses as they become known.
After obtaining a signed Medical Waiver and Consent Form (Form C-31) from 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.
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. Claimants and employers must be notified of the decision of compensability within fifteen (15) days of the notice.
If an insurance carrier denies a claim, a Notice of Denial of Claim For Compensation Form (Form C-23) must be filed with the Division and a copy of that form must be provided to the claimant at the same time. The insurance carrier 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.
Upon making its determination after a proper investigation, the employer, self-insured employer, or insurance company must file, with the Division, the following appropriate forms:
- Notice of Denial of Claim For Compensation Form (Form C-23). Employers, self-insured employers, and/or insurance carriers shall file Form C-23 on a paper form and may file through Electronic Date Interchange (EDI) in addition to the paper form.
Notice of First Payment of Compensation (Form C-22). Employers, self-insured employers, and/or insurance companies shall file Form C-22 through EDI.
Notice of Change or Termination of Compensation Benefits (Form C-26). immediately upon each change or termination of compensation benefits through EDI.
Notice of Controversy (Form C-27) shall be filed in those cases where payments have been made without an award and the employer or insurance carrier subsequently elects to controvert its liability.
PAYMENT OF BENEFITS
Compensation payments for an injury shall be received by the claimant no later than fifteen (15) days after notice of injury.
All workers’ compensation benefits shall be issued timely to assure the injured employee receives the benefits on or before the date they are due.
RESOLUTION PROCESS
A medical impairment rating and date of maximum medical improvement by the treating physician, and information needed to settle a claim shall be documented in writing.
Insurers shall make an offer of settlement in writing within thirty (3) days of receipt of information specified above, 0800-2-14-.06(1). The claimant shall sign the offer of settlement indicating approval or rejection of the offer.
An agreed settlement shall be finalized by order of a court or approval by the Division as required by TCA §50-6-206. A copy of the court order or division approval shall be filed with the Commissioner of Tennessee Department of Labor.
If settlement is not agreed upon a Benefit Review Conference may be requested pursuant to TCA §50-6-237.
MEDICAL COSTS
All medical costs owed under the Tennessee Workers’ Compensation Law must be paid according to the Rules of the Medical Fee Schedule, Chapters 0800-02-17, 0800-02-18 and 0800-02-19. Those Rules are available on the Secretary of State's Web page athttp://www.tn.gov/sos/rules/0800/0800-02/0800-02.htm.
The employer or insurer must file the following reports with the Division when applicable:
- Attending Physician’s Report (Form C-30)
Final Medical Report (Form C-30A) shall be filed in accordance with Rule 0800-02-17-.25, although a party, in lieu of a deposition, may utilize the Standard Form Medical Report For Industrial Injuries (Form C-32).
ENFORCEMENT
In addition to other penalties provided by applicable law and regulation, violations of any of the above rules may be subject to enforcement by the Commissioner of the Tennessee Department of Labor pursuant to TCA §50-6-419(c). The Penalty Program rules, Chapter 0800-02-13, are available on the Secretary of State's Web page at http://www.tn.gov/sos/rules/0800/0800-02/0800-02.htm
RESOLUTION PROCESS
A medical impairment rating and the date of maximum medical improvement, as determined by the treating physician, and all other information needed to settle a claim must be documented in writing on the Attending Physician’s Report (Form C-30). Insurance carriers must make an offer of settlement in writing within thirty (30) days of their receipt of this information. The claimant must indicate approval or rejection of the offer and sign the offer of settlement.
An agreed-upon settlement must be finalized by either an order of a court or an approval by the Division as required by TCA §50-6-206. A copy of the court order or Division approval must be filed with the Commissioner of Tennessee Department of Labor. If a settlement is not agreed upon a Benefit Review Conference may be requested.
Employees and/or employee representatives shall submit to the Division notice of filing of any lawsuit concerning workers’ compensation benefits. A (Notice of Lawsuit (Form C-28) must be filed to satisfy this notice requirement.
Final Report of Payment and Receipt of Compensation (Form C-29) must be submitted in all cases that are not settled, are not tried, and do not result in permanent disability payments. Employers, self-insured employers, and/or insurance carriers must file a Form C-29 with the Division through Electronic Data Interchange (EDI) within thirty (30) days following the final payment of compensation. Form C-29 shall include all compensation benefits paid on a claim, including all medical expenses, hospital expenses, funeral expenses, and legal costs.
Statistical Data Form (Form SD-1) shall be filed for every workers’ compensation matter that is concluded by settlement, either by a court or the Division. Each employer or employer’s agent that is a party to a workers’ compensation case must file Form SD-1 with the clerk of the court in which the case is concluded and also with the Division at the conclusion of the case. An order of the court is not final until a Form SD-1 is fully completed and filed with the clerk of the court. In cases involving a workers’ compensation settlement which is submitted to the Division for approval, a copy of Form SD-1 shall also be completed and submitted to the Division at the time of the submission of the settlement for approval. A settlement approved by the Division is not final until a Form SD-1 is fully completed and received by the Division. The employee and any agent of the employee must cooperate with the employer in completing Form SD-1.
FREQUENTLY ASKED QUESTIONS—CLAIMS
What should I do if I am injured at work?
An injured employee should immediately report any work-related accident, injury or illness to their employer. Employer notification, preferably in writing, is required by law within 30 days of the date of injury or when a physician first tells the employee that his/her injury is work related. Employers covered by the Tennessee Workers’ Compensation Act must submit all known or reported injuries or illnesses to their insurer on Tennessee Employer’s First Report of Work Injury or Illness (Form C-20) within one (1) working day of knowledge of the injury or illness. Insurance carriers and self-insured employers must file a Form C-20 with the Division through Electronic Data Interchange (EDI) as soon as possible, but not later than fourteen (14) days after knowledge of the injury or illness.
Can an employee be fired for reporting a work injury?
No. It is unlawful for an employer to terminate an employee for reporting a work injury. Wrongful termination is not addressed under Tennessee Workers' Compensation Law. The employee may wish to consult an attorney to pursue this cause of action through the court system
After receiving a report of a workplace injury, what information should be given to the injured employee?
Upon the report of a workplace injury, an employer should provide the employee, in writing, a choice of three physicians not associated together in practice. An Agreement Between Employer/Employee Choice of Physician (Form C-42) must be completed, a copy given to the employee, and the original kept on file with the employer. In the event of a reported back injury, the choice of physicians is expanded to four names, one of whom must be a chiropractor. The physicians listed should be located in or near the employee's community of residence. The employee has the privilege of choosing a physician from the list. The one selected becomes the “treating physician.” The employee is then required to accept treatment from the treating physician and should not seek treatment from any other medical provider unless the treating physician makes a referral.
The employer should also have a "Tennessee Workers' Compensation Insurance Notice" posted so the injured employee can see the name of the insurance carrier. If the notice is not posted, the employer should tell the injured employee who the insurance carrier is and how to reach the insurance carrier.
Is the injured employee paid for the time involved attending physician’s appointments during work hours?
Generally no, unless it is company policy.
Should the injured employee receive doctors' bills?
No. A health care provider should not bill or sue an injured employee for all or part of the costs of health care services provided to the injured employee unless:
- The injury is found not to be compensable under workers’ compensation law
The physician, who was not authorized by the employer at the time the services were rendered, knew that he/she was not an authorized physician; or
The employee knew the physician was not authorized and it was not an emergency.
What if the employee is unhappy with the physician he/she selected from the employer's panel?
Under Tennessee law, the employer or insurance carrier is not required to offer a second panel of physicians or a second opinion. If asked, however, the insurer or employer MAY provide a second panel. An employee may always seek a second opinion or obtain treatment with any physician at his/her own expense. However, only the restrictions of the authorized physician must be followed by the employer.
Who pays Workers' Compensation benefits?
Benefits are paid by the employer or the employer's workers’ compensation insurer. The Tennessee Department of Labor and Workforce Development does not pay workers' compensation benefits.
What is an injured employee entitled to?
Employees who have suffered a compensable workplace injury are entitled to receive the following:
A. Disability Benefits:
If the employee’s injury is determined to be compensable and the employee is unable to work, temporary benefits will be paid. Compensation is not paid by this division, but by the employer's insurance carrier, unless the employer is self-insured. If the employer is self-insured, compensation is paid directly by the employer or its representative.
Weekly benefits are paid if the authorized treating physician finds that the employee is unable to work due to the injury and misses more than seven days of work. If the employee is out more than 14 days, benefits will be paid from the first day the physician finds that the employee is unable to work due to the injury.
The Workers' Compensation Law sets limits on the maximum and minimum amounts of weekly compensation paid to injured employees. The average of the employee's gross wages will determine the weekly rate. The amount of the benefits are calculated using two-thirds of the employee's average weekly wage over the 52 weeks prior to the injury.
B. Medical Benefits:
The employer should provide the employee a Agreement Between Employer/Employee Choice of Physician" (Form C-42) as explained above.
If specialized treatment is required, the authorized treating physician may refer the employee for such specialized treatment at which time another panel of specialized physicians should be offered.
Medical treatment, at no cost to the employee, extends for as long as required by the authorized treating physician. If appropriate, the physician will provide the employee with off-work excuses and light or restricted duty limitations. It is very important that the authorized treating physician's instructions and restrictions be followed at all times.
Mileage reimbursement for travel to and from medical treatment is allowed if travel, either to or from medical treatment, exceeds 15 miles. The mileage rate is based on current mileage allowance for Tennessee state employees.
C. Permanent Disability and Final Settlement:
When the injury has healed and maximum medical improvement (MMI) is reached, the injured employee will be released from the physician's care.
If the injured employee does not recover completely, the physician should assign a permanent impairment rating.
The impairment rating, combined with vocational factors, may result in a permanent disability award.
Workers' Compensation Specialists with the Tennessee Department of Labor and Workforce Development conduct, at no cost to the parties, informal Benefit Review Conferences to assist the parties in reaching a final agreement or settlement of the claim. Please complete the Request for Benefit Review Conference (Form C40B) and submit it to the Workers' Compensation Division to request a Benefit Review Conference.
Scheduled Injuries
Thumb |
60 weeks |
Second or middle finger |
30 weeks |
Third or ring finger |
20 weeks |
Fourth or little finger |
15 weeks |
Great toe |
30 weeks |
Any other toe |
10 weeks |
Hand |
150 weeks |
Arm |
200 weeks |
Foot |
125 weeks |
Leg |
200 weeks |
Eye |
100 weeks |
Hearing (one ear) |
75 weeks |
Hearing (both ears) |
150 weeks |
*Body as a whole |
400 weeks |
*The 400 weeks for body as a whole is used for a maximum for Permanent Partial Disability (PPD) but does not apply to Permanent Total Disability (PTD).
Reconsideration of a Permanent Partial Disability settlement: The workers’ compensation law places a cap on permanent partial disability awards in those cases where an employee returns to work for the same employer at the same or greater rate of pay as before the compensable injury. If the injury is to a scheduled member rated 200 weeks or more (as identified in the Tennessee Workers’ Compensation Act), and if the injured employee loses his/her job within those number of weeks (following the date the injured employee returned to work), he/she may be entitled to a reconsideration of his/her original permanent partial disability settlement. The job loss must be due to factors other than quitting or being fired for cause. For example, if the employee lost his/her job due to a lay-off, he/she may be entitled to reconsideration. Contact the Tennessee Department of Labor Workforce Development's Workers' Compensation Division for additional information.
D. Death Benefits:
When an injury results in the death of a covered employee, benefits are available to the surviving dependents.
Burial expenses for the deceased employee are paid, not to exceed $7,500.
When the deceased employee leaves no dependents, $20,000 shall be paid to his or her estate.
What if the authorized physician orders light or restricted duty?
If the authorized physician returns the employee to work with specific temporary restrictions (light duty) and the employer provides a job within the restrictions, the employee MUST return to work and attempt the light duty.
The employee may qualify for temporary disability benefits if the employer does not provide a job within the restrictions given by the authorized physician.
The authorized physician determines what duty is appropriate for the restrictions. The physician should be contacted for clarification if the employee believes the work is beyond the restrictions. Failure to report for light duty may terminate disability benefits.
What happens if the injured employee is released to return to work on light duty, but light duty is not available?
Following a work related injury, during the course of treatment, the treating physician may determine an injured employee can return to work on “light duty.” The employee should get a detailed description of work restrictions from the doctor to provide the employer. If the employer can provide work within those restrictions, it should do so. If the employee is paid a lesser pay or is restricted to fewer hours because of the light duty, the employee is entitled to "temporary partial disability" benefits. These benefits are figured at 66 2/3% of the difference between the light duty wages and full duty wages, subject to the same maximum and minimum workers' compensation rates described above.
Example:
An Employee was earning $300.00 per week before being injured.
The same Employee is earning $200.00 per week while on light duty.
$300.00 minus $200.00 equals $100.00 difference in pay due to the light duty restrictions.
66 2/3% of $100.00 equals $66.66.
Therefore, the Employee will earn $200.00 in wages and receive $66.66 in workers' compensation temporary partial disability benefits.
However, if the employer is unable to meet the restrictions provided by the treating physician, the injured employee will remain off work and his/her disability benefits will continue.
Will I have to use my own sick time to cover my time off work?
Generally, no. However, an employee injured and off work fewer than 14 days is not paid for the first seven days under Workers' Compensation Law. Consult the employer about the use of sick or Family Medical Leave time for this time period.
How and when are payments made to the injured employee?
When the treating physician takes an employee off work due to a work related injury, the workers' compensation insurance carrier may be required to make temporary total disability benefit payments to the injured employee. The first payment is due within fifteen (15) days of the employer’s knowledge of the injury and benefits should be paid at least semi-monthly.
In order to qualify for workers’ compensation payments, an injured employee must have a doctor's statement for time off from work. Workers’ compensation payments are not required to be paid for the first seven (7) days of missed work. However, payments begin with the eighth (8th) missed workday. If the employee continues to miss time from work through fourteen (14) missed workdays, the original seven-day waiting period will be paid and the employee will be due benefits retroactive to the first day of missed work.
How much will the injured employee receive in benefits? How are the payments figured?
An employee is entitled to 66 2/3% of his/her average weekly income as long as the amount is within the established maximum or minimum amounts. To determine this, the employer must submit a wage statement to the insurance carrier. This wage statement will list an injured employee’s gross earnings for the fifty-two (52) weeks prior to the date of injury and should reflect all earnings including overtime. The weekly disability benefit rate may not be higher or lower than maximum and minimum rates in effect on the date the employee was injured.
To determine the benefit, gross earnings are totaled and divided by 52 (the number of weeks in a year). The result is the employee's average weekly wage. The average weekly wage is multiplied by .6667 to determine the employee's weekly compensation rate.
Note: If an employee has worked for that employer for less than 52 weeks, the weekly compensation rate must be figured by one of the following methods:
A. By counting the number of weeks the injured employee has been employed by the employer and calculating gross earnings for those weeks. The gross earnings are divided by the number of weeks employed;
or,
B. By calculating the average weekly wage earned by a person employed with the same employer performing the same job as the injured employee during the 52 weeks prior to the injury.
When do workers' compensation benefits stop?
There are several circumstances under which benefits stop:
- When an injured employee is released by their treating physician to return to work.
Whenever an injured employee refuses to comply with a reasonable request for medical examination or to accept medical treatment, compensation may be stopped for the period of time an employee continues the refusal.
Whenever the employer or insurance carrier has been paying benefits and discovers those payments were made in error, the insurance carrier can stop payment but must file a Notice of Controversy (Form C-27).
When an injured employee’s treating physician determines the employee has reached maximum medical improvement (MMI), and the compensability has not been contested. Payments must continue until the earlier of the following events:
an injured employee accepts or rejects a job offered by the employer at a wage equal to or greater than the employee's pre-injury wage, or
a benefit review conference is held and a report is filed.
Payments for employees whose injuries result in a permanent disability cannot exceed a) 60 days beyond the determination of MMI or b) the value of the permanent partial disability award calculated by using the medical impairment given by the treating physician. The injured employee should be offered a settlement in writing by the insurance carrier within thirty (30) days of receipt of the medical impairment rating.
How is a settlement determined?
A settlement is appropriate in cases when an injured employee reached maximum medical improvement but the employee has a permanent impairment resulting from the work-related injury. The employee’s treating physician will determine, in writing, a percentage of impairment and will state the part of the body affected. This is called an “impairment rating.” There are many variables in the computation of a rating but the percentage will be based on standard criteria used by all physicians to determine the percentage of impairment retained. A Workers' Compensation Specialist for the Workers’ Compensation Division can assist in determining an appropriate range of settlement for the resulting vocational disability.
Who may I contact with additional questions?
Regardless of your role in the matter, if you have issues or questions concerning any part of a claim, the Division’s Benefit Review Program assists employees, employers and insurance carriers by answering questions and by resolving disputes with workers' compensation claims. The Benefit Review Program can be contacted at wc.info@tn.gov or 1-800-332-2667 or 615-532-4812 (TDD).
Statute of Limitations
The right to receive workers' compensation benefits does not stay open forever. An injured worker must file Form C40B, "Request for Benefit Review Conference," before the time limit runs out. Generally, that is one year from the date of injury, or the date the employer last paid temporary disability or medical bills. Some special circumstances can extend the time to file.
Where do I go if things do not work out?
If you have problems with any part of your claim, the state has a Benefit Review Program that assists employees, employers, and insurance carriers with resolving disputes with workers' compensation claims. The Tennessee Department of Labor and Workforce Development's Workers' Compensation Division can be contacted at 1-800-332-2667 or 615-532-4812