The employee must report the claim event to the employer, who in turn notifies the insurance company. The claim is formally initiated by the employer’s notice, launching the claim process.
The employee or a care provider may also initiate the claim and notify the insurance company in writing. The notification must specify
- the employer’s name and contact information,
- details of the incident
- the employee’s name, date or birth or personal identity code, and contact information.
In addition, the care provider must submit the patient records for the treatment appointment.
The insurance company notifies the employee after the claim has been initiated. The insurance company must also ensure that all the documents necessary for making a decision on the claim are at its disposal as soon as possible.
The insurance company must, on its own initiative, pay any compensation to which the employee is entitled under the Workers’ Compensation Act and on the basis of received information.
For certain types of compensation, the claim must be submitted within one year after the costs were incurred. These include:
- medications and treatment supplies
- travel and accommodation expenses;
- increased costs incurred from home help
- items broken during the claim event
- compensation for pay for the period of examination
- compensation for pay for a period of physiotherapy
The purpose of the hearing is to facilitate the processing of the claim and provide the injured employee with an opportunity to express his/her views on the matter. The employee must be heard before a decision is issued on the claim. The employee must be given the opportunity to provide an account of their requests and any information that may impact the decision.
A hearing is not needed when the insurance company accepts the claim in its entirety or when a hearing is manifestly unnecessary for some other reason.
The employer participates in the claim processing by submitting a notification of the claim event to the insurance company. The employer may be asked for other information during the processing, such as details of the employment relationship, earnings or rehabilitation.
Statement by the Accident Insurance Compensation Board
In certain cases, before a decision is made on a claim, the insurance company must request a statement from the Accident Insurance Compensation Board on its proposed decision. These include, for example, cases with a high disability category, vocational rehabilitation lasting more than one year, and certain permanent pensions.
Time limit for the insurance company’s decision
The insurance company must issue its decision on the claim promptly and no later than 30 days from the date when it has received adequate information to resolve the matter. If the time limit is exceeded, the insurance company will pay an increase for delay.
If the insurance company has not initiated the claim processing or issued the decision within the time limit, the employee can apply to the Workers’ Compensation Center (TVK) to ask for the delayed claim to be transferred to, and processed by, TVK. The transfer request can be made with a free-form application to TVK in writing.
Format, content and grounds of the claim decision
The claim decision is issued in writing and must clearly indicate the following information:
- the authority issuing the decision
- the date of the decision
- parties directly affected by the decision;
- the grounds for the decision
- itemised information on the rights and obligations of the parties, or how the claim has been otherwise resolved, and
- name and contact details of the person who can provide further information on the decision.
The insurer must provide grounds for its decision. If the claim is rejected and the rejection is based in its essential parts on medical grounds, the grounds for the decision must indicate the factors that mainly influenced the assessment and the conclusions drawn on the basis of these.
Appealing a claim decision
A person who is dissatisfied with the decision issued by the insurance company can appeal to the Employment Accidents Appeal Board. Appeals against the Board’s decisions can be lodged with the Insurance Court. In some cases, appeals against the Insurance Court’s decisions can be lodged with the Supreme Court. The decision must include instructions for lodging the appeal.
The appeal is submitted to the insurance company that made the decision. The insurer will first consider amending the decision on the basis of any new information obtained. If the decision is not amended, the appeal is submitted to the Appeal Board.
The appeal is made in writing and may be in a free format. The appeal period is 30 days after the employee has received the decision.
The Employment Accidents Appeal Board processes the appeals free of charge. A court fee may be charged for the proceedings in the Insurance Court and the Supreme Court in accordance with the Court Fee Act.