Include Future Medical Exposure in the Settlement While many claims settle with the payment of statutory benefits, there are claims needing further consideration. In the states where the medical portion of the workers' compensation claim cannot be closed, the adjuster needs to evaluate possible future medical exposure and take the appropriate steps to conclude the medical where appropriate at the same time the disability claim is concluded, even if it involves payment for estimated future medical expense. If the medical portion of the claim is not settled, in most states the employee will have the right to unlimited future medical coverage (with actively treating time restrictions in some states). For example, if the employee has a disability rating to their lumbar spine and you leave the medical open, your company may be paying for the chiropractor bills for rest of the employee's life, or even worse, paying for surgery possibly unrelated to your work comp claim. (Note: Most plaintiff attorneys will want to resolve the future medical, especially if they are entitled to a portion of the medical settlement in their fee). To establish the value of the open medical, the adjuster will need to rely on the insurance company's/TPA's medical director for the amount of future medical care needed. In most cases, the adjuster can multiply the number of future doctor visits by the cost per visit to get an estimate of the value of the future medical expense. When the employee's future medical cost cannot be determined or future medical care is expected to be minimal, the adjuster should still make a nominal payment (large enough to satisfy the workers' compensation board/industrial commission) to settle the future medical. The adjuster will need to obtain the employee's signature on the appropriate release or settlement form(s) used in their state to document the resolution of the future medical claim. Determine the Disability Rating/Permanency Rating In about half of the states, the employer can select the treating physician for the employee. As part of your risk management plan, a list of approved conservative physicians selected by their area of expertise should be established before an injury ever occurs. The employee can then be directed to the approved physician who provides the necessary medical care without keeping the employee out of work any longer than necessary. Employer-selected and approved physicians less likely to overstate the disability rating as a plaintiff's attorney-selected physician might be inclined to do. In these states as soon as the employee reaches MMI, the adjuster needs to take the doctor's permanency rating and apply it to the disability schedule utilized in that state. In the states where employees can select their own doctor to treat them for their injury, the adjuster needs to be ready to immediately refer the employee for an Independent Medical Exam (IME) or Peer Review when the treating physicians states the estimated disability. If the disability rating given by the employee's physician is low or acceptable to the adjuster, a referral for an IME may not be needed. If the adjuster, medical director or nurse case manager questions about the validity of the permanency rating given by the employee's physician, then proceeding with a prompt IME is essential to controlling the settlement value of the claim. In those states where the workers' compensation board/industrial commission often splits the difference between the permanency rating given by the employee's physician and the permanency rating given by the employer's physician, the IME is absolutely necessary for a fair settlement of the claim. The area of the claim where the plaintiff attorneys or the employee most often try to capitalize is in establishing the permanency rating. Plaintiff attorneys will try to send the injured employee to a doctor with a reputation for being generous with (overstating) the disability ratings, not to the doctor who will provide the best medical care to the employee. The reason the plaintiff attorneys do this is to maximize their earnings, because they are paid a percentage of what the employee receives. Resource: http://reduceyourworkerscomp.com//documents/Doc-List-by-Module.pdf Superior Employee Communication The best way to prevent the involvement of an employee's attorney is proper on-going contact with the employee. While there will always be some employees who are very claims conscious and will obtain an attorney despite the best efforts of the adjuster, most employees get an attorney when they don't know what to expect or they do not feel the adjuster is helpful. When both the employer and the adjuster maintain good rapport with the employee throughout the medical recovery, the involvement of the plaintiff attorney is often eliminated. The adjuster should always direct the employee to a physician, where doing so is not barred by statute, who will provide prompt, complete medical care and provide an accurate permanency rating. In states where the employee has the right to select the physician and the employee's attorney sends them to a medical provider who provides the highest medical rating, the adjuster should continuously press the treating physician for current medical reports. In addition, all allowable examinations by an Independent Medical Examiner should be completed at the appropriate time(s) to provide an accurate permanency rating. (workersxzcompxzkit) If the employee's physician gives a high rating and the employee's attorney is unwilling to settle for the IME rating, then the timely use of defense counsel becomes necessary to adjudicate the differences in the permanency rating. Impairment Rating Firms are often used to evaluate the correct rating according to the edition of the AMA guidelines, or ODG, used in your state. One such firm is Impairment Resources at www.Impairment.com. These are MD's who research then write an report based on objective evidence, not a physical exam of the claimant, specifying the correct impairment rating. If you use such a firm, remember to include it in your account handling instructions. According to www.Impairment.com, the average error rare of impairment ratings is over 70%, and the vast majority of those errors are over (not under) rated. TO DOWNLOAD OR LISTEN TO FREE AUDIO PODCAST click here: http://www.workerscompkit.com/gallagher/mp3 By: Anthony Van Gorp, private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers' comp issues. ©2009 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact [email protected]
