Famous last words in an insurance office are that the next claim is never going to be the next worst one. The fact remains that you never know which day, or which new claim, is going to be your next major pain. With that being said, the initial stages of investigation are going to determine whether or not you have a chance of a solid defense. And if you can’t defend then you may be able to at least contain and control the claim, which are important factors in resolving the claim overall.
A Disputed Claim Is Won In the First 2-3 Days of Filing The Claim
While going through the investigation, you have to think long term. Not 2-3 months long term, but 2-3 years long term. What questions do I need to ask now that will come in to play down the road? Did we confirm that this person is not a Medicare beneficiary? Is there other employment, or self-employment out there that we do not know about?
What if we decide to totally deny this claim? I recall a manager a long time ago telling me that a disputed claim is won in the first 2-3 days of the filing of the claim. This is when the crucial steps are being completed to lay the template for claim defense. The adjuster is gathering information applicable to the facts of the claim. What happened, why it happened, and on so on. It really is true that the who/what/where/when/why/how are the main questions you have to address. Also witness statements are important while they can still remember the incident. A witness is worthless if you try to interview them a year later about a work injury.
Other important questions to ask are follow-up questions. An example would start off:
“What did you hurt?” and the answer may be “My low back.”
This is fine, but the next question should be “In addition to your low back, did you injure anything else?”
If the answer is no, that is great. Especially if 6 months from now this worker tries to add their shoulder or neck in to the claim. If you have the worker put all of this down in their own writing, that they signed and dated, now you have some compelling evidence other than the HR person’s own notes which may or may not be paraphrased and overall not helpful to case defense.
Be Thorough In Investigating Scene
Time and time again we say on this blog to go out and check out the scene where the accident happened. Be thorough in reporting what you find, especially if the claim is questionable. Is there fluid on the floor? Is the carpet slick?
One thing to note is not to let the injured worker know that you plan on going out and doing a scene investigation. Get the information from the injured worker first, then go out and check out the scene right after. Even more helpful is to bring another worker with you that can also help you check out the scene and sign off on the report as a witness to your investigation. Almost all cell phones can take video and/or pictures, so take some video and pictures of the scene to add to the file. Take note of any pain behaviors the claimant is exhibiting, such as limping, sitting/standing posture, eye contact, etc.
Have Injured Worker Take You To Scene
If possible take the injured worker out to the scene and have them slowly show you what happened, and videotape or take pictures for later reference. Carefully document the mechanics of what happened, and document in normal terms and not “shop talk” so a doctor can understand the mechanism of injury and what the worker was doing exactly at the time of injury.
Too often employers have to pay more on claims based on the lack of a proper and thorough investigation. But at the same time, you have to discriminate which injuries to perform a full-blown investigation on. A safe assumption is any injury involving a joint or a spine is a red flag for a thorough investigation. Lacerations and simple burns or abrasions you can bypass.
Remember, strong and effective investigative efforts early on in the claim by supervisors and managers can have an immediate impact on the outcome of their claims. This will reduce work comp costs, and have a positive impact on their workers comp program.