The experience and expertise of your adjuster will have a significant impact on the cost and life of a workers’ compensation claim. Every employer must be absolutely certain the adjuster handling claims knows what, how, and when to do everything from the first report of injury to the final disposition.
Claim supervisors and managers need to be the most experienced, as well as have sufficient time to monitor staff and claim handling. They also must teach, critique, and discipline all claim handling.
An adjuster needs to be part detective, part doctor, part lawyer, part father confessor, part director, and part politician. Investigating facts and activities requires an inquisitive mind with questioning capacity.
Additional Adjuster Tasks & Responsibilities:
- Adjusters must know medical facets of traumatic injury, healing periods and usual complications.
- Proper medical care must be achieved.
- Adjusters must direct and control the claim.
- Complying with the law’s requirements and duties requires legal knowledge.
- Listening, being empathetic, and addressing injured worker needs, is paramount to successful resolution.
- Adjusters must be good communicators in spoken and written format.
- Adjusters must have convincing gravitas to have people accept their proposals.
- Adjusters deal with all walks of life. They must be comfortable in public dealings.
- A college degree might be preferred, but it is not always necessary.
There are two schools of thought for selecting adjusters. First, hire only experienced people. Second, train your own. Both have pros and cons. Each has had successes and failures. Selection is a matter of choice.
Medical Only Technician:
Medical-only adjusters, an entry level position, are trainees with little to no experience. They handle minor medical claims involving simple lacerations and minor strains/sprains not involving any lost wages or complicated medical injuries/conditions. When an employee has a few clinic visits the employer sends the claim in with the bills and the adjuster sets up the claim, processes the bills, and closes the claim.
Some issues a medical technician faces are:
- The history of the injury occurrence may only be addressed in the first reporting and billing.
- Aggravations for underlying pathologies may be casually addressed or not commented on.
- Often a treatment number is the only clue that the employee is being treated for more than the original injury.
- Treatment time and expense exceeds normalcy or claim unit authorities.
- Treatment may be going on that was not authorized.
- Missing permanent partial disabilities. Or paying permanent partial disabilities as a med case instead of an indemnity case.
Lost time/indemnity adjuster
Lost-time/indemnity adjusters are more experienced, with knowledge of local legal statutes and a high degree of medical training in handling occupational claims. Their expertise is with claims running past 90 days involving more severe injuries such as a complicated lacerations, level 2/3 sprain/strains, surgical repairs, or pending surgeries. When employers question claim compensability, the claim is immediately assigned to the lost time/indemnity adjuster.
Some issues that could hamper performance are:
- Assigned case overload impeding ability do a proper job
- Performing tasks that are better served clerically
- Failure to be analytical and innovative
- Have attitude issues that can cause cases to explode
- Failure to explore the worst case scenario
- Lack of empathy for the injured employee
- Lack of effort to resolve cases promptly and expeditiously
Litigation adjusters handle claims involving lawsuits. These adjusters share the same level of experience as the lost-time adjuster. However, they have advanced training in legal issues and in investigating the compensability of occupational claims.
When a compensable claim is disputed, and the claimant retains counsel and files a Notice for a Hearing, the claim goes from the lost-time adjuster to the litigation adjuster. The litigation adjuster works with in-house or outside counsel gathering details on the injury, and appears for hearings and mediations to quickly resolve the claim at minimum legal expense.
This level of adjuster is the most complex, handling very difficult claims, usually ones where the claimant has a severe injury requiring multiple surgeries, amputations, loss of sight, hearing loss, or internal medical issues such as asbestosis or chronic joint degeneration due to occupational exposure, etc.
General/catastrophic adjusters have many years of experience in the Insurance industry, combined with advanced medical and litigation training and experience. They also have advanced claim investigation training, and may possess a law degree or are licensed attorneys.
It is vitally important for adjusters to have the proper intelligence, personality, and training to obtain maximum resolution of their claims. Cases should be assigned at proper levels of adjuster competence. Supervisors, managers, and employers need to monitor adjuster activities to maintain maximum benefit for the claim.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder of COMPClub, an exclusive member training program on workers compensation cost containment best practices. Through these platforms he is in the trenches on a working together with clients to implement and define best practices, which allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: email@example.com.
©2016 Amaxx LLC. All rights reserved under International Copyright Law.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.