Accident Fund Claims Process and Resolution Made Easy

Accident Fund is dedicated to providing a smooth claims process, with a focus on getting you back to work quickly and efficiently. You can file a claim online, by phone, or through the mobile app.

The claims process typically begins with a phone call to Accident Fund's dedicated claims team, who will guide you through the next steps. This team is available 24/7 to take your call.

Accident Fund's claims process is designed to be user-friendly, with a clear and concise process that makes it easy to navigate.

The claims process is a crucial part of the accident fund.

The State Accident Fund assigns a unique claim number upon receiving the First Report of Injury (WCC Form 12-A). This number is used to identify the claim and should be included in all correspondence.

Letters acknowledging receipt of the claim are sent to the claimant and the employer once all required information is received.

The initial reserves for the claim are set as an estimate of the total claim cost.

Most compensability decisions are made within five to ten business days after reviewing the report and gathering additional information.

In cases involving death, heart attack, mental stress, or psychological disorder, the claim is sent directly to the Special Investigation Unit.

The adjuster determines compensability by reviewing the report and gathering necessary information.

If the claim is denied, the letter states the reason for denial.

A claim is generally resolved in one of three ways: through a WCC Form 16, an Order issued by the South Carolina Workers' Compensation Commission, or a settlement.

An Agreement and Final Release relieves the employer and insurance carrier from further responsibility for payment of compensation or medical expenses, unless otherwise stated.

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Under the South Carolina Workers' Compensation Law, an injured worker is entitled to reasonable medical care for the duration of their injury.

The State Accident Fund utilizes "managed care" companies to assist in reducing medical costs. Trained nurses review medical findings and work with medical providers to ensure injured workers receive high-quality medical care.

The employer or employee should forward medical bills to the State Accident Fund, including the State Fund claim number. The adjuster reviews all medical bills and reports, approving authorized treatment and sending them to the Accounting Division for processing and payment.

In South Carolina, injured workers are entitled to reasonable medical care for the duration of their injury.

The State Accident Fund uses "managed care" companies to reduce medical costs and ensure high-quality care.

Trained nurses review medical findings and work with medical providers to speed healing and reduce disabilities.

The State Accident Fund will review all medical bills and reports if the injury is compensable.

Approved medical bills are sent to the Accounting Division for processing and payment.

Denied medical bills are returned to the medical provider with an explanation.

Lost Time Compensation is crucial for employees who can't work due to an injury. The employer and State Accident Fund must communicate about the claimant's status.

If an employee is out of work for less than seven days, they're not eligible for temporary total disability payments. This is a common scenario, but it's essential to understand the rules.

If an employee is out of work for more than seven days but less than fourteen days, they're eligible for lost time benefits starting from the eighth day. This is a key point to remember.

The adjuster will calculate the amount of lost time and the rate of payment. They'll take into account the employee's average weekly wage and the maximum amount set by law.

If the employee is totally unable to work, their compensation rate will be two thirds of their average weekly wage, up to a maximum amount set by law. This is a standard calculation used by the adjuster.

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The adjuster will complete the first section of a WCC Form 15, which explains the compensation rate and the period covered by the check. This form is essential for the claimant to understand their benefits.

If the employee is represented by an attorney, these items are sent directly to the claimant's legal representative. This is an important consideration for employees who have hired a lawyer.

A running award may be established if the nature of the employee's injury indicates a prolonged absence from work. This means automatic generation of weekly benefit checks, payable directly to the claimant.

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A settlement is typically prepared after the employee has reached Maximum Medical Improvement, and the medical provider sends a letter to the State Accident Fund with an impairment rating.

The adjuster evaluates the case and determines the degree of disability or disfigurement, if appropriate, in accordance with established guidelines.

In South Carolina, claims are generally resolved in three ways: through a WCC Form 16, an Order issued by the South Carolina Workers' Compensation Commission, or a settlement.

A WCC Form 16 is an Agreement for Permanent Disability/Disfigurement Compensation, which can be used to settle a claim.

An Order may be issued as a result of a formal hearing.

Claims settled on a WCC Form 16 or by an Order can be reopened within one year from the date of the last compensation payment if the injured worker undergoes an adverse change of condition.

The burden of proof lies with the claimant to show that an adverse change of condition has occurred.

An Agreement and Final Release relieves the employer and insurance carrier from any further responsibility for payment of compensation or medical expenses, unless the Agreement and Final Release specifically provides otherwise.

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If an injury is caused by a third party, such as an automobile accident or product liability, the claimant has options to consider.

The claimant must complete and return an option letter to the State Accident Fund before any benefits can be paid.

In some cases, the claimant may choose to settle with the third party and not pursue a workers' compensation claim, which would close the claim.

If the claimant pursues a workers' compensation claim, the adjuster will manage it in the same way as any other claim.

Recovery from the third party, or subrogation, can be a time-consuming process.

Any funds recovered from the third party are credited back to the claim, directly reducing the claim costs.