The start of the Fall season indicates a new time of year. From back to school time and hunting seasons, to the start of the hustle of bustle of the pending Holiday season. This time of year also starts new trends for the claims season as well—an increase in potentially subjective workers compensation claim filings.
Now it is true that subjective claims can happen anytime, but over the years I always notice that this time of year is when a lot of adjusters see increases in what we call “Monday morning claims.” Those claims being filed or brought to the attention to the employer on a Monday.
Always Question a Monday Morning Injury
Unless there is a very objective trauma involved, I always question an injury that was filed on a Monday. Especially true when the workers are off on weekends. Don’t get me wrong, I can identify with the reasoning that if you were indeed injured in some sort of capacity the prior week, it is not unreasonable to adopt the “Wait and see if it gets better” attitude. On the same notion, I also know that if a person is really injured, they are going to want medical treatment sooner rather than later.
Adjusters are also very busy come this time of year. Claim reviews, Policy renewals, increased file counts, and their own personal business that they tend to outside of work (Remember–claims professionals have families too). But that should not mean that adjusters are not giving your injury files proper attention and their due diligence for investigations and decisions on compensability.
Here are some warning signs to look for and some pointers to make sure your adjuster has all of the information they need to make a good decisions on the compensability of Monday morning claims:
The onset and nature of the injury.
As you gather the facts on your injured worker, be sure to address how and when the injury occurred. Did the worker cite a very specific incident, or was it a gradual onset that worsened over time? If it was gradual, how long ago did the symptoms start? Did the pain stay in the same location, or is it moving around into extremities? Is it worse now after some rest or is it feeling better?
Did any other workers witness anything or did the worker mention anything to their supervisor?
This may be the most important factor in determining the compensability of this claim. Was the worker working with another coworker when the injury occurred? If so, or if the worker claims they told so-and-so they felt a little tweak in their back, be sure to follow up and talk with that witness now, and not later. The more time that goes by, the less likely that witness will remember anything pertinent to the claim investigation.
If the injured worker states they told their manager or supervisor about the injury, again you have to follow up with that person right away. More importantly, if that supervisor was advised of a potential injury, why were you—the injury contact at the employer—not advised about this injury right away so your paperwork/investigation/medical treatment decision be completed?
Does the injury allegation pair up with the type of work the injured worker does?
One thing to look at closely is if the allegation matches the work exposure of the job tasks. If a worker runs a machine, and their day consists of just running a machine, how could they obtain a back injury from “moving boxes?” If the worker is not supposed to be moving any boxes, how could they get injured from moving boxes? Were they helping out another employee? If so, why? If their job doesn’t entail this exposure, they should not be performing that work in the first place. Plus if they were allegedly helping another employee, and you talk to that other employee that was involved, how could that employee not see an injury or notice some sort of injury taking place? I am all for teamwork and for other employees helping each other, but someone should have seen something if there was a tweaking injury of some sort. If not, I would question the nature of the injury involved.
Why did the injured worker not tell you—the injury contact for the employer—if an injury did happen?
Saving the best item for last, if said injury happened last week, why were you not advised by the worker? You can imagine some of the answers to this: “You were already gone for the day, I told my supervisor I thought that was all I had to do, I didn’t think I would need treatment for it, I didn’t want to make a big deal about it, I didn’t want to have to go to the clinic for treatment, I need to keep working I don’t want to miss time from work”… and so on.
But the biggest violation may not be the employee’s fault, it could be yours. If they did not know they were supposed to tell you about a near-miss or incident-only injury, this is the most important problem you have at your work. Workers need to know that should any incident happen, they come to you to report an incident.
Your Workers Need To Know You Are There To Help Them
This doesn’t mean you have to file a claim, or send them for treatment, but you have to be notified every single time. This way, a paper trail can be created, and you can properly follow up to see if they do need treatment later on. This is always a problem at every employer, but it is such a simple one to correct. Your workers need to know that you are there to help them, not fight against them.
In these late-reported claims, I go back to the adage mentioned above: If a worker is really hurt at that specific time, chances are they would get treatment. So complete your investigation, pass the results and statements on to your adjuster, and let them take it from there. And remember, if something doesn’t seem right, it probably isn’t. Trust your gut instinct.
Author Michael Stack, Principal, COMPClub, Amaxx LLC. He is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, and founder of COMPClub an interactive training program teaching workers’ comp cost containment best practices. Through this platform he is in the trenches on a monthly basis with risk managers, brokers, consultants, attorney’s, and adjusters teaching timeless workers’ comp cost containment strategies, as well as working with members to develop new tactics and systems to address the issues facing organizations today. This unique position allows him to continuously be at the forefront of innovation and thought leadership in workers’ compensation cost containment. Contact: email@example.com.