A great deal of work on workers compensation files is completed over the phone. The claims examiner does recorded statements on usually every claim that is questionable or involves lost time away from work. But it is not only this statement that is pertinent to the claim investigation. An adjuster talks to a claimant several times throughout the life of a claim. In fact, most claimants are quick to pick up the phone and call their adjuster all the time, since the adjuster is the one in charge of their claim.
If the adjuster is a proactive listener, phone conversations can also tell clues about the daily activity of a claimant, especially if they are totally out of work, or on a “no activity” status from their physician. Are they on a cell phone? Do they answer the phone? Are they driving, at a grocery store, with kids, etc? All of these things can come in to play later on, and can tip the examiner to maybe pursue some surveillance if the person is potentially more active than they say they are.
Below we discuss a few things to look for as far as background noise is concerned, and what the adjuster can do to get the answers to the lingering questions:
Listen for background chatter from kids or infant babies
Most injured workers have the goal of getting back to work as soon as possible after they are injured. But, this is not always the case with every worker. One thing to look out for is the mention of a baby on the way, or a baby’s cry in the background. I have heard of several claims where the injured party stated they had to get back to work as soon as possible because a baby was on the way. Later on in the claim, the injured worker becomes harder and harder to get a hold of. They can start to miss doctor or therapy appointments, when 30-60 days ago they had perfect medical attendance. The employer can also cue you in on the potential arrival of a bundle of joy in the near future for said injured worker.
It is natural for a parent to want to spend a lot of time with a newborn, or with their younger child. Once a work injury happens, it becomes easy for the parent to get used to the extra time at home with their kids, and all of the sudden they get used to that lifestyle in general. They are not working, but getting paid weekly work comp payments. If they are at home it also means they could be saving hundreds of dollars per week by not having their children in daycare, so a secondary gain issue becomes a problem with this claim.
So listen for clues about a baby, or baby on the way, and be sure to note the file as this info can come in handy later on when you cannot figure out why the injured worker was once doing so well and then all of the sudden became a major problem in getting back to work, be it light duty or full duty.
Let the claimant talk as much as they want to
A good adjuster will always be willing to listen, sometimes for over an hour at a time, when their claimant calls with questions or problems with their claim. Since the adjuster has a lot of other files to deal with, it is easy to try and get off the phone as fast as possible. This is unfortunate, because the adjuster could miss out on several clues for a malingering claimant. Oftentimes, the claimant wants the adjuster to do all of the talking. But you can easily turn the tables on the claimant by asking open-ended questions. This forces the worker to start talking, and with some people once they start talking they quickly talk too much, about everything, and this can lead to some helpful clues about what they have been doing or how their medical treatment has been going.
The worker may mention not being able to go hunting or fishing this year due to injury (red flag #1). They may mention not being able to coach the soccer team their son is on (red flag #2). Perhaps the injured worker talks about not being able to ride their motorcycle (red flag #3). They could even go so far as saying they can’t even play with their kids at the park (red flag #4).
Had the adjuster been quick to end the call, they may have missed out on 4 important red flags, all of which could have blown the claim wide open if surveillance had discovered the claimant doing any of those 4 activities. So let the claimant talk, you never know what they will willingly tell you.
Listen if they are driving a car or out running errands
Most of the time if an injured worker is out of work, chances are they are not sitting at home 100% of the time waiting to heal and get better. Good adjusters know that if they can prove a worker is active running errands, then they can be capable of light duty or sedentary work. This light duty work classification could be something their employer could accommodate if the doctor would give the claimant work restrictions.
So listen to the background noise. If you hear the beeping of a cash register scanner in the background, this means the claimant drove to the store, walked around the store pushing a cart or carrying merchandise, and then drove home and unloaded it. This can all be proven with surveillance. If you get the worker on film running these errands, you can send the video to the doctor, who should then give appropriate work restrictions.
Driving a car means you can sit, move your head, grip the steering wheel, stoop down into the car, and so on. Being able to go get groceries means you can walk around, push a cart, carry grocery bags, etc. When a doctor places a person on “no activity” then this should truly mean no activity. No driving a car, no running errands, no carrying things, etc. You can poke holes into that medical argument with some good surveillance film, which could then lead to medical restrictions for the employee, meaning that they are capable of working in some light duty capacity. This will lower the wage loss expense on a claim, and probably lead to the person going back to work and “healing” faster than expected since you already discovered they were more active than they were leading on.
These are only a few of the things to hone in on when talking to your injured worker. The most important thing is to let them talk, and keep them talking as long as they want to. You never know when they might slip up, and clue you in on some activity or hobby they “wish they were able to do.” Chances are they are doing what they say they are not able to do.
Good surveillance film can be crucial to the defense of a claim, lowering the exposure by leaps and bounds. When done properly, surveillance can be one of the most important defenses you can have on a claim where you have already accepted compensability.
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: email@example.com.
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