Section III - Individual Case Reports

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A. Individual Case Reports Rules

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  1. Claims on Which Required. Individual Case Reports shall be filed for the following:
    1. All death claims
    2. All permanent total claimsNOTE: Delaware has no statutory maximum for incurred indemnity.Individual Case Reports shall be filed concurrently with the submission of individual risk experience.
  2. General Instructions
     for Reporting Information on the Individual Case Reports. ALL INFORMATION ON THE INDIVIDUAL CASE REPORT MUST AGREE WITH THE CORRESPONDING INFORMATION SHOWN ON THE UNIT REPORT.

    1. Forms. For ALL Individual Case Reports (pension and other than pension) use the Individual Case Report form. (See Section VIII.)
    2. Class Code. Report the numeric code to which the loss was assigned.
    3. Report Number Code. Enter the code from the code list in Section IV, Item A.1. of this Plan which corresponds to the policy valuation date.
    4. Transaction Type Code.
      1. Initial Report-Code 1. Must be used for the first time the Individual Case Report for the claim is submitted, regardless of the Unit Statistical Report number based on valuation date.
      2. Subsequent Report-Code 2. Must be used on all Individual Case Reports submitted for a particular claim subsequent to the valuation date for which an initial Individual Case Report (Code 1) was submitted.
      3. Revised Report-Code 3. Individual Case Report filed due to the rejection by the DCRB Unit Review System of a previous Individual Case Report filed for a particular claim. All data on the correction report must be identical to the data on the original report except for Transaction Type and the data elements being corrected.
      4. Correction Report-Code 4. Individual Case Report filed when the carrier discovers a need for change on an Individual Case Report previously filed for the particular claim.
    5. Type of Injury Code. Enter the type of injury code as shown on the corresponding unit report for the particular claim.
    6. Carrier Number. Report the 5-digit carrier code assigned to the company by the National Council on Compensation Insurance, Inc.
    7. Payroll State Code. Report the 2-digit numeric code corresponding to the state to which the injured worker’s payroll was assigned. Code “07” is required in Delaware.
    8. Administration File Number. This field is not required by Delaware.
    9. Policy Number. Report the policy identification number as set forth on the policy information page and reported on the corresponding unit report.
    10. Certificate Number. This field is not required by Delaware. Report the 7-digit number used to identify a risk covered under a master policy.
    11. Policy Effective Date. Report the date on which the policy became effective.
    12. Claim Number. Report the claim number as shown on the corresponding unit report for the particular claim.
    13. Claim Status Code. Enter the appropriate Claim Status Code, use 0 for an open claim or 1 for a closed claim.
    14. Date Attorney Disclosure. This field is not required by Delaware.
    15. Loss Condition Codes. These fields are not required since the information is on the Unit Statistical Report. However, if reported, these entries should be identical with the entries in the Loss Condition fields on the corresponding unit report as provided in Section IV, Item C.3.
    16. Jurisdiction State. This field is not required if it is identical to the Exposure State. However, if different, report the 2-digit state code of the governing jurisdiction which will administer the claim and which statutes will apply to the claim adjustment process.
    17. Managed Care Organization (MCO). This field is not required since the information is on the Unit Statistical Report. However, if reported, the code corresponds to the type of organization, which will administer the applicable medical losses of the particular claim. Refer to Section IV, Item C.4.
    18. Insured Name. Enter the full name of the insured as shown on the policy information page and the corresponding unit report.
    19. Accident Date. Enter the date of the accident.
    20. Date of Death. (Death Claims Only) Enter the date of death.
    21. Date Reported. Enter the date at which the application for benefits was filed.
    22. Date of Birth. Enter the injured worker’s date of birth.
    23. Surgery Code. Report the 1-digit code indicating whether the claimant’s injury required surgery. Refer to Section IV, Item D.6.
    24. Attorney Code. Report a 1-digit code indicating any attorney involvement on this claim. Refer to Section IV, Item D.7.
    25. Worker’s Last Name. Enter the last name of the injured worker.
    26. Worker’s Sex. Enter the code for the sex of the injured worker.
    27. Average Weekly Wage. Enter the average weekly wage as computed in accordance with the statutory provisions regarding determination of average wage. The full wage should be reported rather than the wage sufficient to qualify for the maximum weekly compensation. Report amount.
    28. Injury Description Code. This field is not required since the information is on the Unit Statistical Report. However, if reported, enter the three 2-digit codes from the injury description and cause of injury code grid in Section IV, which most accurately describe the conditions of the injury.
    29. Occupation. Give the regular occupation of the worker as precisely as possible and not the specific activity that the employee was engaged in at the time of the accident.
    30. Date Closed. Enter the date the claim was closed, if applicable.
    31. Reserve Type Code. Report the type of reserve on which this claim is based. Refer to Section IV, Item D.8.
    32. Lump Sum Indicator. Report whether or not the claim was settled with a payment of a specified amount to the claimant. Report “Y” for a lump sum payment and “N” for other than a lump sum payment.
    33. Fraud. Report the code that indicates whether the claim was declared fraudulent. Refer to Section IV, Item D.10.
    34. Social Security Number. This field is not required by Delaware.
    35. Date Single Sum Paid. Enter the date single sum settlement was paid.
    36. Employment Status. Report the employment status of the claimant at the date the claim was first reported to the carrier. Refer to Section IV, Item D.11.
    37. Year Last Exposed. Report the year in which the claimant was last exposed to disease to determine benefit.
    38. Date of Hire. (Not applicable in Delaware)
  3. Specific Instructions for Reporting Information on Individual Case Reports, Other Than Pension.
    1. Temporary Indemnity
      1. Number of Weeks. Report the number of weeks upon which the temporary indemnity benefits is based.
      2. Incurred Loss. Report the total incurred indemnity amount (paid plus outstanding) as of the valuation date of all benefits to the injured worker related to temporary loss of earnings due to loss time from work as a result of an injury or disease.
    2. Scheduled Indemnity.
      1. Percent Disability. Report the percentage of loss, or loss of use, of the specific extremity, digit, vision or hearing on which the benefit is based.
      2. Body Member Code. Report the 2-digit numeric code corresponding to the part of body on which the benefit is based. Body member codes are to be used only with scheduled indemnity cases. Refer to Section IV for the code list and schedule.
      3. Number of Weeks. Report the number of weeks upon which the scheduled indemnity benefit is based.
      4. Incurred Loss. Report the total incurred indemnity amount (paid plus outstanding) as of the valuation date of all scheduled benefits. Report dollars only.
    3. Non-Scheduled Indemnity.
      1. Percent Disability. Report the percentage upon which the non-scheduled indemnity benefit was determined.
      2. Incurred Loss. Report the total incurred indemnity amount (paid plus outstanding) as of the valuation date of all non-scheduled benefits based on a percentage disability. Report dollars only.
    4. Employers Liability or Other Indemnity.
      1. Employers Liability. Report the incurred cost of the claim settled in accordance with Section I, Item L.7. of this Plan.
      2. Other Indemnity (Excluding Vocational Rehabilitation). Report the total incurred indemnity amount (paid plus outstanding) as of the valuation date of all wage loss or other benefits (excluding vocational rehabilitation) not included in a., b. or c. Any payments to special funds should be reported in this field. Report dollars only. Identify the type of indemnity reported, i.e., wage loss.
    5. Vocational Rehabilitation Total Incurred. Report the incurred amount (paid plus outstanding) of any vocational rehabilitation expenses incurred as of the valuation date. The corresponding Vocational Rehabilitation Indicator also must be used. See Section IV.
    6. Claimant Legal Expense. Report the incurred cost of the claim in accordance with Section I, Item L.9. of this Plan.
  4. Specific Instructions for Reporting Information on Individual Case Reports, Pension Benefits.
    1. Beneficiary Data. Report the 1-digit numeric code corresponding to each different type of beneficiary. Refer to Section IV, Item D.12. for the code list. A separate code must be given for each beneficiary even if more than one beneficiary falls within the same code. For each beneficiary report the date when the beneficiary was born.
    2. Pension Indemnity Benefits Paid to Valuation Date. Report the total amount of pension benefits paid as of the valuation date, excluding any lump sum remarriage payment. Report the amount rounded to the nearest dollar. This amount must exclude all amounts reported under Item 3. above (Other Than Pension).
    3. Pension Indemnity Previously Reserved, Not Paid. Report the pension indemnity amount previously reserved but not yet paid. (Accruals).
    4. Pension Value of Future Indemnity Payments. Report the present value of total future indemnity payments. Report amount rounded to the nearest whole dollar. Refer to Items C.7.a. and C.7.b. of Section II for additional instructions.
    5. Funeral Allowance. Report the amount of funeral allowance rounded to the nearest whole dollar.
    6. Lump Sum Remarriage Payment. Report the amount paid upon the remarriage of the injured worker’s spouses. Report amount rounded to nearest whole dollar.
  5. Totals
    1. Total Incurred Indemnity (Sum 1-11). This amount must be identical to the Indemnity Losses shown in the Incurred Losses section of the corresponding unit report.
    2. Total Incurred Medical. This amount must be identical to the Medical Losses shown in the Incurred Losses section of the corresponding unit report.
    3. Total Indemnity and Total Medical Paid to Valuation Date. Enter the totals of indemnity and medical that been paid as of the valuation date.
    4. Social Security or Other Offset Amount. Enter the whole dollar amount of any social security or other offset paid as of the valuation date.
    5. Calculations. Use this space to show any pertinent calculations or remarks.
    6. Physician Paid. This field is not required in Delaware. Enter the whole dollar amount of benefits paid as of the valuation date to treating physicians, including the cost of all clinic and office visits.
    7. Hospital Benefits Paid. This field is not required in Delaware. Enter the whole dollar amount for all benefits paid as of the valuation date to a hospital.
    8. Applicants Medical Evaluation Paid. This field is not required in Delaware. Enter the amount paid as of the valuation date for medical evaluations procured by the applicant or the applicant’s attorney, excluding evaluations performed by the treating physician or by a qualified medical evaluator (QME) selected from a panel for a non-represented worker.
    9. Defense Medical Evaluation Paid. This field is not required in Delaware. Enter the amount as of the valuation date for medical evaluations procured by the insurance carrier, excluding evaluations performed by the treating physician or by qualified medical evaluator (QME) selected from a panel for a non-represented worker.
    10. Independent Medical Evaluation Paid. This field is not required in Delaware. Enter the amount paid as of the valuation date for medical evaluations procured by agreement of the parties or by appointment by the governmental agency, including the cost of an evaluation performed by the treating physician acting in the capacity of an agreed medical evaluator.
    11. Legal Expense Defense. Report any legal expenses paid on behalf of the defense. This element shall not be included in the incurred losses. See Section I, Item L.9. of this Plan.
    12. Annuity Purchased Amount. Enter the total purchase price (cost to the carrier) of the annuity purchased.
    13. Total Gross Incurred. This field is not required in Delaware.
    14. Temporary Disability Paid. This field is not required in Delaware. Enter the total dollar amount paid as of the valuation date in temporary disability benefits.
    15. Permanent Partial Disability Paid. This field is not required in Delaware. Enter the total dollar amount paid as of the valuation date in permanent partial disability benefits.
    16. Permanent Total Disability Paid. This field is not required in Delaware. Enter the total dollar amount paid as of the valuation date in permanent total disability benefits.
    17. Death Paid. This field is not required in Delaware. Enter the total dollar amount paid as of the valuation date in death benefits.
    18. Single Sum Paid. When a case involves complete or partial commutation of future payments, report the actual loss payment. Enter the total dollar amount in indemnity benefits that have been paid as of the valuation date as a single amount.
    19. Vocational Rehabilitation Paid. Enter the total dollar amount paid as of the valuation date in vocational rehabilitation benefits (including training, evaluation and vocational rehabilitation indemnity).