63 Items To Look For In Your TPA or Carrier Claim Report

Your company is self-insured and hired a Third Party Administrator (TPA) to handle your workers’ compensation claims.  As part of the servicing agreement with your TPA, the TPA agreed to complete a written report within 14 days of assignment on new workers’ compensation claim s with reserves over $10,000.   Here are some guidelines as to what the reports should contain.

All reports should be laid out in a consistent format for ease of reading. The reports should provide you with all essential information without you having to go on-line to read the entire claim file. The better adjusters will always use the same format, but if the adjuster does not, feel free to provide the following reporting sample outline for captions and sub-captions to the adjuster.   This is the minimum you should expect to see in the initial claims’ reports.

Coverage

Some adjusters will want to skip the coverage caption figuring your company would not have reported the claim if it was not covered. That can be a big mistake if your deductible, self-insured retention or other terms of coverage change at renewal or any other time).

1. Policy number (if one is assigned) and policy dates
2. Applicable deductible, self insured retention , endorsements
3. Alternative or duel coverage 

Description of Accident

1. Date and time of day
2. Place (Where the accident occurred on the premises, or other location if off the premises)
3. What was the employee doing when the injury occurred
4. Regular job for the employee or outside the norm for the employee
5. Date the accident was reported to supervisor or manager
6. Date the accident was reported to the claims coordinator for your company

Insured

1. Name of Unit/Division/Branch
2. Location (Street address, City & State), also the location code number (if one is assigned)
3. The nature of the business/work performed at this location 

Employee

1. Full name
2. Age/Date of Birth
3. Number and relationship of dependents ( in states where dependents affect indemnity benefits)
4. Detailed job description/occupation
5. Length of employment, length of time in current job description
6. Prior injuries, both work com and liability claims reported to the index bureau
7. Summary of recorded statement or interview
8. Social security (edited for confidentiality if required by state law)
9. Education level of employee
10. (If represented) Attorney for employee—name, address, expertise 

Jurisdiction

1. Statutory state benefits
2. Federal (Longshore & Harborworkers Act, Federal Employment Liability Act, Jones Act)
3. Potential Employers Liability exposure 

Compensability

1. Why the claim is compensable
2. Why the claim is being controverted 

Reserves

1. Amounts for indemnity, medical, legal, rehabilitation and other expenses should be individually stated
2. Adequacy for life of claim should be discussed 

Indemnity Benefits

1. Average weekly wage amount and how documented
2. Compensation rate and how calculated
3. Specific benefits due to permanent impairment, scarring (where allowed), etc. 

Injury

1. Nature of injury
2. Attending physician(s) and specialists identified
3. Hospitalization, discharged date or anticipated discharge date
4. Type of future medical care and projected length of care
5. Estimated length of temporary total disability
6. Estimated Return To Work date, modified duty and/or regular duty
7. Independent Medical Evaluation (if the jurisdiction allows more than one, if not the IME should be saved until the employee is at maximum medical improvement)
8. Permanent impairment rating (expected or assigned) 

Rehabilitation

1. Vocational
2. Physical
3. Length of rehabilitation
4. Facility or provider
5. Reasons/justification for rehabilitation

Second Injury Fund (in states where it still exists)

1. Nature of employee’s prior injury, disability or medical condition
2. Statutory requirements to access the Second Injury Fund
3. Self insurers’ rights of recovery 

Subrogation

1. Identification of responsible third party
2. Negligence theory
3. Expert testimony (if needed)
4. Preservation of evidence
5. Issues affecting pursuit of subrogation such as hold harmless agreements, contracts, business relationships, possibility of a cross-claim against your company
6. Recovery amount
7. Employee’s right of recovery

Litigation/Legal Expense

If the claim is being contested before a workers’ compensation board or in a court, the following information is needed:

1. Defense attorney’s name, firm’s name, address
2. Issue(s) in contention
3. Probable outcome
4. Legal budget

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Action Plan

1. Steps to be taken to move the file forward
2. Barriers to resolving the claims 

Diary for Future Reports

1. Date an updated status report will be provided 

Attachments

1. List of attachments or documentation being provided, if any 

Summary

The adjuster’s report should provide you with all the information needed to keep you totally informed about the claim in question.   If after reading the adjuster’s report you still have questions, add a caption or category to reporting format to answer your question on all future work comp claims.

The adjuster should provide status reports on a regular basis of 30 days to 90 days depending upon the developments on the claim. Status reports should not repeat the information provided in the initial reports, but only cover the categories where there has been a change or a new development that impacts the claim.

Proper reporting by the work comp adjuster will make your life easier in the management of your self-insured program.

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: mstack@reduceyourworkerscomp.com.

Workers’ Comp Roundup Blog: https://blog.reduceyourworkerscomp.com/

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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.