Why THE EMPLOYER Must Talk to a Doctor BEFORE Settling a Claim

Medical Issues

Both the work comp adjuster and your work comp coordinator need to have a solid understanding of common medical problems faced by employees recovering from on workplace injuries. When either the adjuster or your work comp coordinator does not understand the nature of an employee’s medical issues they need to either research the medical issue by contacting the treating physician or your insurance company’s/TPA’s medical director BEFORE SETTLING THE CLAIM.

A discussion explains the medical issue and how it will affect the employee long term. A complete understanding of the medical issue(s) facing the employee is necessary for a proper evaluation of the value of the claim. The internet may also be used (judiciously) for research.

Often a stumbling block to the successful settlement of a work comp claim is the lack of understanding by the employee of the medical issue(s) currently being experienced. The nurse case manager on the file should always be present at the employee’s conference with the treating physician when the future prognosis and future treatment and care are discussed. The nurse case manager can assist the employee in obtaining answers to all questions about the medical condition. This helps to alleviate the employee’s fear about the future, making it easier for the adjuster to settle the claim.

Disputed Issues

Disputes are unavoidable in the handling of work comp claims. Disputes arise from almost all aspects of the claim including whether or not the medical issue is work related, the amount of the temporary total disability benefits, the medical benefits provided, the disability rating and the value of future medical benefits. While disputes cannot be totally eliminated, the adjuster can reduce the number of disputed issues and reduce the contentiousness of the disputes.

As part of the Best Practices established by your Risk Management Department, you require the adjuster to make immediate contact on each new claim reported, plus you have required the adjuster to maintain regular contact with the employee throughout the course of the claim.

The employee is primarily concerned about all aspects of the claim being handled promptly and fairly. The rapport built up by your adjuster with the employee through regular contact eliminates many disputes. If the employee contacts the adjuster whenever there is a problem or a question rather than an attorney, the end result of the claim will be much better. If the employee does not hear from the adjuster in months, the employee will have no confidence in being treated fairly by the adjuster to resolved problems.

When the employee is represented by an attorney and a dispute does arise over what will be paid, the adjuster must have a thorough understanding of the work comp laws in their state. http://reduceyourworkerscomp.com//laws_and_regulations.php

Most jurisdictions have previously resolved every imaginable type of dispute over wage benefits. What is and what is not covered can usually be found in either the written statutes or case law. The knowledgeable adjuster can point out to the employee’s attorney the governing law or ruling defining and determining what is owed/not owed. (workersxzcompxzkit)

The area of disputes most often in contention is medical benefits. When the employee’s doctor selected by the employee’s attorney wants to continue treatment beyond what is necessary, or the employee wants to try the latest unproven experimental treatment, it is essential for your IME doctor to be highly proficient in his/her specialty. Your IME doctor must be able to testify if necessary as to why the medical treatment sought by the employee/employee’s attorney is not justifiable.

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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 broker about workers’ comp issues.

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