It is important for even the most experienced claims handlers to brush up on their claims investigation skills. Doing so adds a layer of diligence to one’s claims investigation and improves client satisfaction. It also provides an opportunity to look at things from a different angle and reduce workers’ compensation program costs in the long run.
Interviewing the Injured Worker
An effective claims management and investigative tool is the interview with the injured worker. Not only are they a witness to the incident, but it can also help the claims handler and the team evaluate the case. This includes the character and believability of the employee.
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Important information to obtain from the injured employee includes:
- How did the injury occur?
- What type of work were they performing just prior to the incident?
- How did they report the injury?
- What was the extent of their injury?
- Where did they receive medical care and treatment before and after the incident?
It is important to be friendly and remember the injured worker is a human being who deserves to be treated with respect and dignity. One can empathize with the employee and still be an advocate for the insured. Be sure to remain calm and establish rapport.
Determine Other Witnesses
This requires a member of the claims management team to act like a detective and ask the right questions. Witnesses not only includes people who saw the incident occur, but others who know the employee’s habits and conduct. It can also include people involved in the recovery of the employee.
Important information to obtain can include:
- Activities or interests of the employee beyond work. Do they go to a certain restaurant? Whom have they received medical care and treatment from in the past? What organizations do they belong to?
- A determination as to the employee’s educational and vocational background. It is also important to know if they have been involved in prior workers’ compensation claims or personal injury litigation.
Injury Site Reconstruction
Many denied or disputed claims rest of the proposition that an injury could not of occurred based on the described mechanism. This is often relevant in repetitive injury cases where the employee is claiming the injury occurred over a period of time. In these incidents, it is important for a medical or vocational expert to provide expert opinion testimony as to the physiological aspects of a claim.
Members of the claims management team may also need to work with a client who is not cooperative. In order to capture this evidence, it is important to develop professional relationships and educate the insured on injury site reconstruction and evidence preservation prior to the occurrence of an injury.
Understanding the Law
Lawyers are a great source of accurate information concerning the law in workers’ compensation matters. However, members of the claims management team need to understand the law. The goal is to reduce program costs by limiting attorney referrals to those instances where it is necessary.
In the meantime, members of the claims management team can be proactive in this area without getting a law school education. This can include:
- Hosting defense attorneys for “lunch and learn” opportunities;
- Attend continuing education programs with an emphasis on state specific rules and case law trends; and
- Use in-house roundtable sessions to better determine what cases should be referred to legal counsel.
Conclusions
It is important for members of the claims management team to master the basics when handling workers’ compensation files. This includes frequent refresher courses on handling claims with an emphasis in reducing workers’ compensation program costs. This includes simple things that include interviewing witnesses, including the employee, and understanding this law.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers compensation cost containment systems and helps employers reduce their work comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center. .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.
