Pretend for a second that this is a headline/title of an article in a magazine:
“Workers Comp is a broken, maimed, dated system. It is set up to protect employers and insurance companies. It shifts the burden and the blame of occupational accidents to the employees while at the same time protecting employers under exclusive remedy and/or tort recovery.”
I hate to admit it but that would get my attention. Not only would I raise an eyebrow at that but I would be chomping at the bit to see what would be coming in the following paragraphs.
Now, turn the page and imagine seeing this as the headline that follows:
“Workers Comp helps employees with injury recovery, top medical treatment, expedited claims processing, and an allowance of return to full wage work before medically released to perform regular duties.”
That doesn’t bait me as much as the other paragraph, but I am still a little interested. The truth is that both of these statements ring correct in some capacity. They also both grossly stereotype workers comp at the same time, depending on which side of the case you are on.
Workers Comp is a System
In my opinion, work comp is a system. It is a system that has been around a long, long time. It has failed to really evolve with the times until recently in some states. It protects employers from tort action and third party pain/suffering lawsuits in exchange for claimants to receive medical treatment and wage recovery. Injured workers also receive free help from nurse case managers, vocational experts, surgeons, therapists, transportation professionals, etc.
There are issues with both parties. Employees feel pressure about conforming to the work comp system, and fight to get what they think—or what they heard—or what they Googled–they are entitled to. Employers and Carriers feel pressure to move these claims along to resolution to get claimants back to work as soon as possible. Adjusters have tools to get to the bottom of injuries and to defend their employer client from cases that are not acceptable under applicable comp statutes in the State of jurisdiction.
Both sides have made the system what it is: a dysfunctional relationship.
Clear Communication and Expectations See Successful Results
However, this is not the case example with every carrier/adjuster/employer/claimant. In those cases where there is clear communication, clear expectations, and clear examples of patience and of teaching, you see something different. You begin to see a partnership between all parties. The employee that can no longer return as a welder now discovers that he has to turn over a new leaf. With the help of a vocational expert they discover that teaching is the real passion. The adjuster helps to facilitate providing the training program and this partnership results in said worker securing a job with a new employer. The pay is not as much, but clear communication between the adjuster and the claimant showed that settlement of the partial wage loss was the best option for all parties.
The jaded reader of this will think the above example is a rarity in the claims world. But I think that every adjuster has had a few successes in their careers. And if every adjuster has had a few of these cases, that means there has been a lot of successes.
Breakdown in Communication and Expectations Leads to Claims Disasters
But there are also examples of claims disasters as well. One of the main contributors to a claim disaster is a breakdown in communication and a breakdown of expectations. As soon as this relationship crashes, the rest of it comes crashing down as well. Both parties become suspicious of secondary gain, of breaking the rules, and of skewing the truth. Every adjuster has some examples of these types of cases as well, and there are tons going on right now.
Studies have shown that fraudulent claims are not the norm, and that disputed claims are the minority of the claims caseload. I think the number hovers around 10% or less that fall in to this category. So that means the other 90% are legitimate claims. So why is this bad relationship aura so prevalent? Why is the default opinion that the comp adjuster is “Just out to send me back to work. I am hurt–don’t they understand?”
The answer is poor communication. We preach about the importance of communication between all parties all of the time including the adjuster, employer, claimant, nurse, and doctor. The adjuster has the job of making sure all parties are communicating. If there is a breakdown in the process, the adjuster has to step in and fix it and then smooth it over with the offended party. Failure to do this makes the adjuster’s job more difficult, sending the claim sliding in to Disaster-ville.
It is just another aspect of the profession of the claims adjuster–playing the peacemaker. One of the 9,000 things that adjusters do every day, on every claim, for every client big or small. The better the peacemaker, the better the communicator, the better success for the adjuster.
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 protected].
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