Most workers that are injured are quick to blame their employer if an issue arises with coverage or denial of their work comp claim. Once you break away the layers of the injury details it can start to tell a different story. Oftentimes the failure to communicate will fall on the shoulders of the employee, who should know better to begin with.
For example, take a case of a knee injury in which the worker banged his knee on a metal frame while working. At first he thought the pain would go away, so he didn’t say anything right away. Later on in his shift, while his supervisor was walking by he shouts out to him that he hurt his knee, and that was it. The supervisor barely hears him in passing, and continues about his day. A week later he limps over to the HR department and wants to go to the clinic to treat. This is the first the HR person or work comp supervisor is hearing of an injury.
Who Is To Blame For An Unreported Injury?
So where is the fault in this scenario? Is it the injured worker who fails to actually talk to his supervisor and fill out an accident report? Or is it the supervisor who fails to follow up with the worker to find out what he said?
In my opinion, the fault is on the worker. Most carriers and employers are soft on this issue. If someone casually reports an injury, then waits a week to start treating it, you have no way of confirming what happened during those days he was allegedly injured and not treating with a doctor. In the end it becomes the workers version of the story versus the supervisors. In my book, if both sides fail to agree, then it is a disputed file and no benefits should be paid out.
The worker has the burden of proving that he was injured in the course and scope of employment. He also has to show how he was injured, what injured him, who he told, if he had witnesses, and all the other tidbits that go in to proving and having a claim. If the worker fails most of these issues, then how can an adjuster in good faith deem a claim like that compensable?
It should be an open and closed denial, but it is not. More often I see claims like this accepted, treatment is covered, and then surgical costs and wage loss benefits are paid out on a claim that had no business being paid. Leakage all over the place! Plus if you are self-insured or on a high-deductible plan, that is your money going right out the window.
Avoid Problems With a Clearly Communicated Accident Protocol
To avoid these situations, you have to have a clearly communicated air-tight accident protocol process. Steps have to be laid out and communicated to your workers on what their responsibilities are should an injury occur. You have to stick to your process you have in place, and any non-compliance should result in a claim denial and also disciplinary actions for failure to report a claim handed down to the allegedly injured employee.
This is what will get the attention of your workforce on the floor. Discipline and enforcement are the only two options you have. If you give one guy a break on the protocol, then you have failed your own system that is set up to protect you.
Enforcement of these measures will have to be drilled in to the heads of your supervising staff. They have to know if a worker comes to them with an injury, they have to stop what they are doing and complete the incident paperwork. Creating this paper trial is essential to the work comp process. Failure to comply on the supervisor’s part should lead to the same disciplinary measures that your other workers are held to. This makes it fair for everyone, and keeps the chain of communication running. Any breakdown of that line of communication fails the system.
A Work Comp Case is Either 100% or 0% Compensable
Going back to the adjuster’s point of view, I always say a compensable work comp case is either 100% or 0%. It can’t be a case where you think the worker is 70% legit and then pick up the case as compensable based on that. Even if the injured worker has a compelling story, if the employer cannot give the same injury details or scenario then they had a breakdown in communication somewhere. They have to figure out what went wrong before you can move the case forward one way or the other. I tell employers that disputes can be filed asking for more time to investigate the case. Sometimes the supervisor finally admits that yes, the worker came to them with an injury and they failed to complete the paperwork. The worker has witnesses, an objective injury, and no secondary motive to lie about it. One side will eventually have to give.
As claims professionals, we cannot be everywhere at once. In my opinion, you are always better off letting the investigation proceed, than just picking up the case as compensable only later to find out that the employer had tons of issues regarding the compensability of the case after completion of their own investigation.
Use investigative means wisely, and hold the employer to their own due diligence on their investigation as to what happened and why it happened. Remember, if it is not 100% clear and compensable, it is 0%.
Author Michael B. Stack, CPA, Principal, 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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