It is important for members of the workers’ compensation claim management team to document their files properly. If you do not have access to the electronic claims file, now is the time to ask. If not, it should be a condition of claim handling agreement with your third-party administrator (TPA) or insurer.
What is in a Properly Documented File?
Several items need to be in a properly documented claim file. Important issues concerning coverage should be addressed at every step of the claim. This should include:
- The policy number;
- The policy coverage period;
- The states or jurisdictions covered by the policy;
- Endorsements to the policy; and
- Exclusions from the policy coverage.
If you have questions, be sure to ask – and demand prompt answers before the adjuster proceeds with the contacts and with the investigation.
Points of Contact Following a Work Injury
Prompt contact with all parties should be initiated immediately after the report of the claim. Demand action is being taken on the same day a claim is received, or within 24 hours of the loss. Points of contact should include, but not be limited to the following:
- The employee;
- The employer;
- Any witnesses to the injury. All contact information for witnesses should be included as people change jobs over time; and
- The medical provider(s), including ambulance services and law enforcement responding to a work injury.
The clock is ticking. Steps taken during the initial phase of a claim are important. Other important notes from a claim handler should be noted. Important information to obtain should include:
- Accident details as stated by the employee in the recorded statement, the employer’s version of the accident, and any witnesses’ version of the accident;
- Index Bureau information and any history of prior insurance claims;
- Analysis regarding the potential for subrogation;
- The current disability status of the employee, and projected return to work date;
- The employee’s job description, including title, duties, equipment utilized, etc.;
- Length of time the employee has worked for the employer;
- The availability of modified duty for the employee not yet back to work;
- Information on the nature of the injury, the treatment plan, diagnosis, and the prognosis;
- Subjective information such as the employee’s attitude toward the employer, returning to work, and the quality of the medical treatment;
- The explanation of benefits provided to the employee and the action plan information provided to the employee;
- If there is an attorney representing the employee, if so, obtain the representation agreement.
Moving the Work Comp Claim Toward Settlement
Any time is the right time to move a workers’ compensation claim toward settlement. Steps toward resolving the claim can also be taken after a work injury. Part of this process includes obtaining documentation that is required to evaluate the claim and set reserves. Documentation the claim handler needs can include:
- Recorded statements of the employee, the employer, and any witnesses;
- Medical authorizations. These will be needed to obtain a complete set of medical records regarding other conditions possibility contributing to the employee’s disability;
- Wage records from the employer to calculating the average weekly wage;
- Complete set of medical records. This may include past records, records related to the work injury, and for other records created in the future;
- Other required state workers; compensation forms;
- Police reports, EMS reports, OSHA reports, other governmental reports on an accident;
- Independent medical evaluations (IME) or peer review;
- Vocational and rehabilitation reports;
- Subrogation documentation;
- Second injury fund correspondence and/or documentation;
- Correspondence to/from employee’s attorney;
- Correspondence to/from defense counsel;
- Workers’ Compensation Board/Industrial Commission correspondence and records; and
- File notes on every telephone call, e-mail, or any other activity related to the file.
The claim file may also contain other important information on the claim handler’s efforts to resolve the claim, including:
- Case evaluations and status reports regarding causation, legal defenses, and settlement;
- Exposure analysis and case valuation;
- A synopsis of any legal questions and the efforts to resolve those questions;
- Information concerning the disability rating or the potential disability rating;
- Legal analysis regarding a litigation strategy;
- The “action plan” to bring the claim to a conclusion; and
- A history of the settlement negotiations.
The claim handler’s file notes contain the main details of all file documentation received regarding a workers’ compensation claim. It is important for employers to play an active role in every workers’ compensation claim and be engaged. Failure to do so can prove to be costly and increase program costs. The file documentation itself, whether maintained in the computer or by paper, must be complete and answer any questions you have about the file.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a 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 the founder & lead trainer of Amaxx Workers’ Comp Training Center.
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.