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Claims Process

Claims Initiation

When the First Report of Injury (WCC Form 12-A) is received, the claim is assigned a State Accident Fund Claim Number. This unique number is the primary means of identifying the claim and should be included in all correspondence. Once all the required information has been received, the initial reserves for the claim will be set. The reserves are an estimate of the total claim cost. Letters acknowledging receipt of the claim will be sent to the claimant and 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 Special Investigation Unit where they 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 South Carolina Workers' Compensation Law). Most compensability decisions are made within five (5) to ten (10) business days.

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 uphold the recommended denial, reverse 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.

Payment of Medical Bills

Under the South Carolina 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" has been reached, as determined by the authorized treating physician. South Carolina law allows the employer/insurance carrier to designate a physician.

To assist in reducing medical costs, the State Accident Fund utilizes “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. 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 State Fund 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

Communication between the employer and State Accident Fund is essential 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 calculate 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). 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).

Terminating 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, it is important to notify the adjuster 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 South Carolina Workers' Compensation Commission by completing Section 3, "Notice to Injured Worker or Legal Representative When Temporary Compensation Has Been Stopped" and sending a copy to the South Carolina Workers' Compensation Commission. 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 South Carolina 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" has been reached. This letter will also include an impairment rating. The adjuster will evaluate the case and prepare a settlement. They will determine, in accordance with established guidelines, the degree of disability or disfigurement if appropriate. In South Carolina, workers’ compensation claims are generally resolved in three ways:

- WCC Form 16 (Agreement for Permanent Disability/Disfigurement Compensation)

- Order issued by the South Carolina Workers' Compensation Commission as a result of a formal hearing or,

- Agreement and Final Release

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. It is the burden of 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.

Third 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, the claimant will choose how to proceed and an option letter will be sent. The claimant must complete the option letter and return it to the State Accident Fund. We cannot 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 once 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.