Guide To Claiming Medical Benefits Through Workmen's Compensation Insurance

PNN
New Delhi [India], December 23: When employees face injuries or illnesses while performing their duties, the financial and emotional stress can be severe. In such cases, a workmen's compensation policy is helpful. A workmen's compensation policy is a type of insurance that organisations purchase to protect their employees from financial loss resulting from workplace injuries, occupational diseases, or accidents during employment. The Workmen's Compensation Act governs the policy. Let's discuss the claim process under this policy and also highlight the inclusions, exclusions, and more.
What does workmen's policy cover?
Workmen's compensation policy provides financial support to your employees in the following scenarios:
* When your employee suffers an injury while performing a work task, the policy covers hospitalisation, surgeries, and medication costs.
* If an employee cannot work for a few weeks or months due to a work injury, the policy compensates a portion of their lost wages.
* When a work injury leaves a lasting impairment that affects an employee's earning capacity, the policy provides financial compensation.
* If a work-related accident causes death, the policy pays compensation to the deceased employee's dependents.
* Sometimes, an injured employee or their family may file a legal claim for compensation. The policy covers the legal defence costs and related court expenses.
Step-by-step guide to raising a claim under a workmen's compensation policy
If you have sustained an injury at your workplace, here are the steps you need to follow:
Step 1: The employee must immediately notify the supervisor or HR department once the accident or illness occurs. The concerned person should record the incident in the company's accident register or logbook. If possible, a written acknowledgement of the report should be obtained.
Step 2: The employee must visit a hospital or clinic approved by the employer or insurer. All medical bills, prescriptions, diagnostic reports, and discharge summaries must be retained. If hospitalisation is required, cashless treatment should be opted for.
Step 3: All relevant documents must be collected, organised, and submitted to the HR department.
Step 4: The designated employee will initiate the claim with the insurance company on behalf of the employee dealing with a medical crisis. They will also fill out the claim form and attach all supporting documents.
Step 5: The insurer will appoint a surveyor to verify if the claim is genuine. During the process, they may request multiple documents and ask questions to understand the situation, to which your HR and the employee who raised the claim should respond.
Step 6: Post verification, the surveyor will submit their report to the claim executive, and if everything is in order, they will release the payment.
What does the workmen's policy exclude?
You must communicate to your employees that the workmen's compensation policy does not apply in the following events.
* The policy does not cover injuries that the employee causes to themselves intentionally.
* If your employee sustains injury while performing tasks outside the scope of employment, the policy does not apply. For example, an employee attending a personal errand during work hours and meeting with an accident cannot claim compensation.
* If an employee suffers injury or death while under the influence of alcohol or drugs, the insurer has the right to reject the claim.
* Workmen's compensation applies only to employees legally employed by the insured. If a contractor's worker or an unauthorised person suffers an injury, the policy benefits stand void.
Injuries sustained while committing or attempting an unlawful act are not covered.
* If an employee dies a natural death due to old age, heart attack, or illness not caused by employment, the coverage benefits do not apply.
* Workmen's compensation policies often exclude coverage for employees working outside India unless specifically extended.
Difference between health insurance and workmen's compensation policy
Although both health insurance and workers' compensation provide medical benefits, their purposes and scopes differ.
Health insurance covers general medical expenses, such as hospitalisation due to illness, injury, or surgery. It may or may not be related to work. Employers often offer group health insurance to employees as part of the benefits package.
Workmen's compensation insurance, however, specifically covers injuries, disabilities, or death caused during or due to employment. It includes compensation for loss of income, medical treatment, and rehabilitation.
Tips to support employees returning to work after an injury
Even with a workmen's compensation policy in place, returning to work after a severe injury sometimes needs more than financial support. Here is what you can do as an employer:
* Work closely with the employee's healthcare provider to understand physical restrictions and recovery timelines. For example, if your technician injured his shoulder, get a doctor's written recommendation on permissible movements and lifting limits.
* Modify job responsibilities based on the employee's temporary limitations. Suppose your delivery driver cannot lift heavy parcels due to a leg injury. You can assign them to route planning or administrative coordination.
* Schedule weekly or biweekly meetings to discuss the employee's comfort, workload, and any emerging concerns.
* Review the workspace for ergonomic needs before the employee resumes duties. Try to provide suitable furniture, equipment, or tools that reduce strain and prevent reinjury.
* Recognise the psychological impact of injuries by offering mental health resources such as staff assistance programmes or counselling. Anxiety or fear of reinjury can slow recovery.
* Track performance and health indicators during the initial months after return. Use feedback from supervisors, medical updates, and employee input to assess recovery stability.
Conclusion
A workmen's compensation policy offers a safety net that helps employees cope with financial challenges after workplace injuries. By following the claim process and knowing what the policy covers, employers and employees can handle accidents more smoothly.
Besides financial support, offering a caring environment and adjusting work to suit an employee's temporary limitations helps them return confidently, supporting their well-being and keeping the workplace productive.
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