I think a lot of adjusters believe that a slip and fall injury is an open/closed kind of case. The worker was ambling along during work duties and then slip/fell and was injured. Pretty easy!
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There is a lot more to the story. Many claims professionals who do not thoroughly investigate a slip and fall are losing out on a potential subrogation chance. They are also potentially accepting a claim that they do not have to, depending on the jurisdiction.
Double Check Legal Defense Options
In some states, you have an idiopathic fall claim defense, loosely meaning that if you fell because you are clumsy then that is not exactly in the course and scope of your employment. There is no mechanism that caused the injury, such as water on the floor or a coworker that bumped in to you. This defense does not fly in all states, so be sure to check with local legal Counsel before accepting a claim where a worker just fell and has no idea how or why they fell.
What kind of shoes or boots were they wearing? Did the worker have the proper approved footwear for the workstation or area that they were working in? If not, this could be a company policy violation or a safety violation. This also is not applicable in all states so confirm with Counsel again if there are issues in this area that contributed to the fall.
Subrogation Options
Did Floor Cleaning Company Post Adequate Signage?
Did the worker fall due to the negligence of a vendor that was on premises at the time? If so, you have a clear subrogation case to pursue. For example, if a floor cleaning company was in the area and did not properly rope the area off or they failed to adequately post proper signage that the floors were wet, this is an issue. If that is the case, the vendor has a duty to properly protect and advise other workers in the area that they are cleaning and that floors are wet. Failure to do so is a pretty big deal and presents an avenue to fight the causal relation of the case in general.
Did Outside Vendor Properly Maintain Machine That Leaked Fluid?
Did a machine leak fluid onto the floor where the worker fell? If so, who maintains the machinery? If you use an outside vendor, you may have another subro case to pursue. If you maintain your own equipment, what caused the failure to begin with? If it is more of an engineering flaw more than a mechanical flaw, you have another way to look in to a subro recovery case to help recoup claims dollars spent.
Was The Claim Properly Investigated?
Did you properly review onsite camera footage to see if the worker fell in the way they described it? If you do not have cameras onsite, this is another chance to thoroughly investigate a claim if there were no direct witnesses to what happened. It may not be a slam dunk every time, but even if you were to prove one case as not being legitimate, then the cameras more than paid for themselves.
If there were direct witnesses, did you take a statement from them in regards to what happened? Oftentimes adjusters will ask if a coworker witnessed a fall, then they will fail to follow up on taking a statement. If you do not talk to the witness, why even ask for their names? This is a failure to properly investigate the claim, and overall it is a big no-no in claims investigation 101.
Was the worker supposed to be in the area where they fell? If not, this again is a safety violation and a way to dispute the case in general. If workers are not to be inside the yellow-marked lines, then go inside them anyway and get injured, I think that falls in to willful misconduct. If you go somewhere you are not supposed to be, then get hurt, why is that an acceptable work comp case? If you shove your arm in to a machine and it amputates it off, this is really no different. It comes down to the fact that you were doing something you were not supposed to do. If you are breaking safety protocol, that is not exactly being in the course and scope of your employment.
Did the employer complete a proper onsite investigation after the injury occurred? If not, then they failed to help themselves. Too many times employers fail to properly investigate their own losses before reporting them to their carrier. This fact is probably the biggest culprit in proper slip/fall investigation, and one that is easily fixable. The employer is right there on the scene, they should be the first people looking to see if there was water or oil on the floor, and why it was there to begin with.
Make Sure All the Facts Make Sense
All of these factors come in to play at some point in the proper investigation in to a slip and fall injury work comp claim. All points may not be applicable all at once, but each adjuster has had scenarios where the facts just didn’t make sense, but instead of questioning everything and doing an in-depth investigation, they just accept the claim. This is not acceptable. The job of the claims adjuster is to put the pieces of the puzzle back together. If after doing so the claim just doesn’t add up, then why are they accepting the claim to begin with?
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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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.
