9 Ways to Spot When A Workers Comp Claim Is Going Bad

1. A delay of more than two weeks between the date of injury and the date the injury is reported to the employer. This can be a claim where the employee tried “to tough it out”, but often it is an injury that occurred away from work. A detailed recorded statement should be obtained from both the employee and the employee’s supervisor in regards to the facts of the claim. A medical authorization should be obtained from the employee and medical records obtained from both the employee’s personal doctor and the workers’ comp doctor. Both the claims coordinator and the adjuster need to closely scrutinize the medical reports before accepting this claim.
2. A history of previous injuries to the same affected body part, especially spinal injuries. The employee may have re-injured himself while doing household chores or some other non-work related activity. A medical authorization, recorded statements and a review of the personal and workers’ comp medical history should be accomplished before accepting the claim.
3. An injury that occurs the first day on the new job. It could be the new employee is a klutz or really, really unlucky. Most often, especially for musculoskeletal injury claims, the employee joined your company for the sole purpose of having someone to pay for the medical care she already needed. Again, a detailed investigation into the facts and the medical history of the employee is required.
4. The employee is unhappy with the medical care provided by the doctor(s) and keeps changing doctors. Doctor shopping is almost always either (a) an effort to find a doctor who will keep the employee off work, or (b) an effort to find a doctor who will prescribe the pain medications the employee wants. Either way an aggressive early return to work program is necessary. The employer and the adjuster need to be talking to whoever the current doctor is and describing the light duty job(s) available to the employee. Also, if needed, a nurse case manager should be assigned to control the medications being prescribed.
5. The employee early in the claim — before the doctor has placed him/her at maximum medical improvement –inquires as to what type of settlement s/he will receive. This is a red flag that should put both the adjuster and the employer on edge. It is a clear indicator the employee’s interest is to maximize the settlement, not to recover and return to work. This is another situation where the adjuster and the employer should be working with the doctor to return the employee to a light duty job. Also, a nurse case manager should be involved in the medical care as the employee is probably magnifying his symptoms in an effort to maximize his settlement.
6. The employee has a true, undisputed injury but begins to over utilize pain medications. The employee took one pain pill and it only helped some. He took two pain pills together and felt great. He took three pain pills together and experienced a trip he had never been on before. It is absolutely essential in a situation like this to have a nurse case manager to work with the treating doctors to make sure the employee is not duplicating his pain medications by using multiple doctors. The nurse case manager can also prevent the refill of prescriptions before the prior allotment should run out.
7. The employee works in a state allowing her to select her own doctor and selects a doctor known to be “pro-plaintiff” or “pro-surgery.” This is a difficult one. The adjuster should place an aggressive nurse case manager on the claim right away. The nurse case manager should request a second opinion prior to any surgery. The adjuster should review the state statutes on when and how many independent medical examinations can be had, and use them judiciously. The adjuster, the employer, and the nurse case manager should be encouraging a modified duty or light duty return to work for the employee.
8. The employee is within two years of the retirement age. The employee enjoys his time off work and begins to think this is what retirement will be like. The workers’ comp weekly indemnity benefit is greater than what the retirement pension and/or social security will pay. A light duty program is essential in a case like this. The nurse case manager can work with the doctor to get the employee released to return to work as quickly as possible. The sooner the older employee is back at work, the less likely the employee is to start comparing disability leave with retirement.
9. The employee has recovered enough that the medical care amounts only to a once a month or less frequent visit to the doctor. This often happens when the adjuster has the file on a long diary and is not actively monitoring the claim. When the employee gets to the point of monthly visits, and is not already back at work, the adjuster should be inquiring with the doctor as to when the employee will be released to light duty or modified duty. If the doctor is reluctant to release the employee to return to work, the adjuster should inquire as to why. An independent medical examination may be needed to compel the employee to return to work if the treating doctor will not release the employee to work.

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There other file situations the experienced adjuster should recognize and take steps to control before the claim gets out of hand. If your company has experienced more than its share of claims going bad, please contact us. We will be glad to arrange a file consultant to review your files and identify those that need extra attention before they get out of hand.