Let me first point out this article is written from the Claims Adjuster’s point of view. This will point out a disturbing new trend in the world of insurance where the employer is not being honest about injury details or other information surrounding the injury. Not all of you will fall in to this category, but some unknowingly may. So take that in to consideration, and I hope it impacts you to change the way losses are handled.
Over the years I have investigated workers compensation losses and have heard bizarre stories of personal injury and the circumstances surrounding accidents. If someone asks me if I have seen everything in workers comp, I have to answer an emphatic no Chances are a bigger and more unbelievable instance has yet to cross my desk, and it will be my job as the adjuster to determine what happened. For those employers without the luxury of video surveillance, I have to go by witness accounts ( if there are any) and attempt to piece the circumstances of the injury together.
Sometimes this is a difficult task. Given the job environment in recent years, I have noticed a new trend where employers are being dishonest with me about the details of an injury. This is probably happening for many reasons, but in any case it is never acceptable nor helpful. The carrier is on your side and needs to hear the truth. Below I discuss a few questions I ask on claims where I have heard questionable responses in the past.
What do you know about the injury details?
Every employer has a designated person to call a claim in to the carrier. This person’s name is at the bottom of the report. The first phone call I make after getting the claim is to this person. Today, we will call her Sally. I call Sally and ask her if this is all that is known about the injury. She says yes, and that all details are included in the injury report she completed.
That may be correct, but I know the report is missing information. So I rephrase the question about the exact timeline of events. Who was injured? Did the worker tell someone? Did the worker go to the clinic alone or did someone drive? Do you know about any prior injuries to the claimant’s knee ( for example)? Keep in mind one and two word answers do not assist in creating my report. If you the employer do not know the particulars about the injury then be clear on that at the outset. I will attempt to find someone who is. Perhaps this will be a floor supervisor, field manager, or you can direct me to the appropriate person.
Are there any witnesses?
I can name countless times where an employer reports to me there are no witnesses to an injury. Then I interview the claimant who provides several names as witnesses. Next, I talk to those individuals and ask about their account of events, and more times than not they have seen something or arrived shortly after the accident after hearing the claimant’s calls for help. If there are witnesses, I will learn about it from the claimant and others interviewed.
Perhaps the employer did not ask about witnesses at the time of reporting and was not aware of any. Maybe the internal injury questionnaire does not have the space to write witness names no witnesses. In some cases, the employer may intend for the claim to sound less substantial.
Whatever the case may be, if there are known witnesses, name them. The employer should know the employee will be ready to list as many witnesses as they can remember to substantiate the claim. In the end, finding out there are witnesses makes us question the validity of the employer not the claimant. It makes us question you. And in the case where the employer’s internal report does not have a space for witnesses, that should be immediately added as it will help in any claims going forward.
Why was the claim not called in a timely manner?
Sometimes I get a claim with an injury date months earlier or even a year. Maybe this is an error. But if someone approaches you as an employer and reports being hurt, a claim should be immediately filed. Do not wait and see if they are actually injured or not. Do not wait to see if they file it under personal insurance to avoid a WC claim. Do not let it sit on a desk for 3 months or more. Call in the claim.
The employer needs to call it in because I will question the claimants about dates. If the claimant reports telling the boss on that date a year ago then again four more times. And that was all before the paperwork is filed, then that is not going to behoove you to the carrier. In fact, the employee also will be displeased , and it is going to make them that less motivated to return to work in the first place.
Maybe the report was completed on the injury date and was sent to your agent or broker. That works well, if the agent calls the claim in to us. Agents receive a lot of paperwork from their clients. They do not know the priority of addressing various documents. Maybe the claim was sent to the wrong agent. Or the wrong person at the agency got your fax, and there was no confirmation call to the carrier. Just call it in, and if it is sent to your agent, follow up with them. The sooner the claim reaches the carrier the better.
Do you know of any outside activities the claimant is involved in?
I like to ask employers this question to see how much they know about their employees. In one case, an employer revealed the injured worker helped coach his son’s soccer league. So I conducted some surveillance and recorded the claimant coaching and standing for long periods of time on the sidelines coaching. That kind of tip proves very helpful in a case and investigation. However, if you as an employer cannot be sure about a tip, then tell us. Even a lead can be helpful, because we can investigate the tip. The bottom line is we trust what the employer tells us as we do not know the claimants at all, so answering questions in the most honest and complete way is critical to the success of our investigation.
Were the guards in place?
For those employers with moving machinery, just admit if the guard was off at the time of injury. The employee is going to tell us either way. The guard is there to protect workers, so the worker is fully aware if it is missing. Maybe this leads to a design flaw that our subrogation department can investigate so we can recoup claims dollars spent on this injury.
I know a lot of employers remove or modify machine guards in order to be more productive or in order to have the machine fit whatever kind of material you are working on for your client. Please only have those machines do what they are supposed to do. Modifying the guards can lead to very serious injury, and the costs associated with that loss are far more than any profit you can attain by changing the functionality of machinery. Not to mention the potential impact it has on the life of the worker who may lose a finger or hand, or worse. I have seen a lot of severe injuries from this. And if you do not think it will happen to you as an employer, the only advice I can give you is that every person I talk to that had this type of injury involving a guard removal or modification told me the same thing: “I have done it like that a million times before and never had any problems until now.”
Did you complete an internal accident report and investigation?
As an employer if you have internal reporting or accident investigations then I commend you. You are on the way to becoming more proactive at handling losses. We discuss frequently about reporting, trends, and identifying injury areas.. If you are not internally reporting, then that is okay also. Although, the employer will find it beneficial to do so in the end.
For employers who do not do any type of reporting, please do not tell me you do and then provide me nothing. I will want to see that report to get its information, and I will keep asking for it to put it in my file. If you did not do one, just tell me you do not have one. I will keep calling and emailing until the employer finally tells me there is not an internal report. This does not assist in creating my report..
In the world of workplace injuries a lot of people on the outside think that the carrier has to worry only about the injured worker’s honesty. Sadly the carrier has more to be concerned with in the claim. It is a combination of the two other parties involved in the claim. I have had cases where the claimant has not been honest. I have had claims where the employer has not been honest. In any case, the truth will prevail. If all parties are honest in the beginning, it makes handling the claim that much easier for everyone involved.
Contributed to Work Comp Roundup by an Ajuster who wishes to remain anonymous however he works for a major carrier.
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.
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