Four Critical Points About Questionable Workers Compensation Claims

 

For the most part, workers compensation claims are generally compensable. The general public thinks the opposite, which is that all insurance companies want is to deny coverage for injuries. Not true.

 

In all actuality, probably 80-90% of claims are accepted in the beginning. But, claims can be denied later, down the road for various reasons. The question comes up as to how to properly dispute a claim where there is a question on the compensability, and we outline a few strategies below.

 

Employers, at the time a claim is reported to their carrier, will know a lot more about the claim from the get go than the adjuster. Once a file is received by the adjuster, the claim has to be set up, then contacts to the employee and employer have to be made, medical records have to be reviewed, and after all of that an initial decision on a claim can be made.

 

But if the employer is calling it a questionable claim, it should be marked as questionable right off the bat, so the adjuster can file a dispute that the compensability of the claim is under investigation. Most jurisdictions have a time limit on how long the investigation of a claim can be , and if the adjuster fails to file for that extension within that time limit, the claim could have to be conceded as compensable, at least in the beginning. 

 

This leads to leakage, since claims dollars are being spent on a claim that may not be compensable. It takes time to take statements, get medical records, get past records, do background checks, etc. If an adjuster can file that extension right off the bat then they can take some time to really investigate the claim, and make the proper decision on the compensability.

 

Generally, questionable claims will receive more of the adjuster’s attention towards investigative means as well.  Especially when the employer notes on the first report of Injury that the claim is questionable on their end, this automatically raises a red flag for the adjuster.   The adjuster will review the initial parts of the claim, and can form questions that they will want to ask the employee when taking their statement.  

 

The first call an adjuster will make will be back to you, the employer, asking why the claim is questionable.  Employers can talk to witnesses, and follow up on leads made by other employees that a claim may not be 100% compensable and pass that information on to the adjuster in the beginning of their investigation.

 

All of these issues greatly help the adjuster, and in the end after all the investigation is completed, a proper decision can be made on the claim as to the overall compensability.

 

Throughout the course of an investigation, a claim can start off as compensable. Say an employee strains his back while working. This was a witnessed injury, reported promptly, and the worker was sent for treatment the same day. Usually benefits will be conceded and the claim will be accepted in the initial stages. 

 

But say for example, a month later in the medical records the claimant tells the doctor they hurt their back over the weekend doing yard work, then made it worse while working. This should lead to a dispute in all cases. The adjuster has no way of knowing how bad the claimant had injured themselves while outside of work, and most often the injured worker will not be able to go back and say that the injury/ongoing disability is 100% work related. 

 

Unfortunately, these cases are hard to come by. Claimants are no dummies, and even if this did occur they sure aren’t going to go to an occupational clinic and talk to the doctor about how they injured themselves outside of work. But it does happen, and the adjuster should catch this every time. Using Nurse Triage can reduce the likelihood of this type of claim because the employees speak to a nurse immediately at the time of injury so there is less room to change a story. 

 

For examples like this, adjusters rely on the medical records, and the mechanism of injury. If a claimant states that they sustained a lumbar strain while at work lifting a 20 lb tote of parts, and the doctor finds all sorts of objective evidence on exam of severe, disabling back pain, then something is not right. The lifting of 20 lb. should not have such excessive force that it will herniate multiple lumbar discs.   The adjuster should set an IME, and let that IME physician comment on the severity of the symptoms in relation to the stated work injury. 

 

This type of scenario is a lot more common than you would think. The general public probably has never had a diagnostic workup on their spine, nonetheless an MRI test. If a claimant sustains a simple injury, then after an MRI was completed the MRI is positive for all sorts of issues, it doesn’t mean that they all are related to the work injury.

 

Plus you have to beware of false positives. Just because someone has multiple levels of disc bulges, that doesn’t mean that all of those are related to work. Research has been done that shows workers of all ages and occupations can have a varying level of degree of spinal issues, regardless of age.   It is the adjuster’s job to determine what, if anything, is related to the work injury, treat those issues, and deny ongoing treatment for the rest of the worker’s spinal problems.

 

The answer is all cases is YES. It is the adjuster’s job to determine if an injury occurred out of the course and scope of employment. A Human Resources professional for a company is not an adjuster (at least not very often), and if a worker comes to you and alleges a work injury, no matter what the circumstances, it should be reported to your carrier. The adjuster has training and certification, and they are qualified to deny a claim that is alleged to be work related. Some jurisdictions can carry heavy penalties for failure to report a work injury to their Carrier, and you do not want to be hit with one of those penalties. You pay a premium to a Carrier to protect you in insurance matters, and this is what they are there for.   The employer should gather all the pertinent details, and report the claim promptly. Indicate on the First report of Injury that the claim is questionable, and then go from there. Follow up with the adjuster, and chances are it will be denied as you suspected.

 

There are several way to dispute a questionable claim. But the most important thing to do, as an employer, is to gather all the information you can on the claim, then report it promptly to your carrier and follow it up with a phone call to the adjuster. The more you work together with your Carrier, the better the chance that questionable claims will be denied and not paid.

WC BOOK: www.WCMANUAL.com