When an adjuster reserves a file, they focus on probable outcomes. The medical side of the file is usually pretty straightforward. An adjuster can tell based on risk drivers if a person will need surgery, extended rehab, or other procedures based on their medical history.
Return To Work Becomes Complicated When It’s Unclear
What is more difficult is whether or not this worker will return to work should light duty become available. What complicates the process is when the employer is just not sure if light duty work will open, when it will be available, or if they even want the worker to return at all.
Let me explain by using an example. Let’s say a worker needs a back surgery. The employer has light duty positions open, and tells the adjuster that once the worker has restrictions they will place them in work. So, the adjuster will plan to reserve for when the worker is off work post-operatively, and then target a range of when restrictions should be in place and the worker can get back to work.
What will complicate the file is a delay on the employer’s side in getting the worker into light duty. I have reviewed countless files where the employer has stated early on that work is open, but then delayed placing the worker into the light duty work program for weeks or months after restrictions were placed. This not only affects the indemnity costs on the file, but can inhibit the workers overall physical recovery.
Especially with a back surgery, the sooner you get the injured worker off the couch and back to work doing anything the quicker and easier their recovery will be. The last thing you want is the worker sitting around for weeks waiting for the phone to ring. Even worse is when the worker knows light duty in there, and cannot figure out why they can’t return to work.
Claimant Suspicion Can Lead to Higher Claim Dollars
Then the wheels start to turn in the head of the injured party. Maybe they are going to fire me? Why can’t I go back to light duty when I know other workers that returned to work after they had surgeries? Is my employer mad at me because I needed a surgery? Should I get an attorney just in case I get fired because of all of this?
Then when they talk to the adjuster, most adjusters will have no answers for them as to why they can’t return to work as well. After all, the employer told the adjuster that light duty work would be available. Why is this not happening for this claimant? Is the employer not being honest about something in regards to the employment future of said worker? Should I be reserving this file for vocational rehab and start posturing for a potential settlement?
Failure To Communicate
The culprit here, as in many work comp problems, is a failure to communicate. In this example, the employer laid the groundwork for a simple return to work post-op in the light duty work program they have up and running. If there were some political aspects as to why this worker should not or cannot return to work, the adjuster needs to know. Not only for reserve forecasting, but for general return to work forecasting.
Should light duty work not be open for the employee for whatever reason, the adjuster has options to get the worker off the couch and working. The main option is to use an employment vendor that can find transitional light duty work in their own community. This way the worker is still working in some capacity, until they are released to perform full duty work for their own employer. Other options could include work hardening programs, which can be intensive therapy that can help the worker aggressively rehab and get to full duty status faster than traditional therapy methods.
The result of failure to communicate a return to work will result in under-reserving the file. In the end this helps nobody, and the carrier/TPA in general hates to under-reserve anything. It also will make the carrier question the validity of a light duty program in general, and many questions will start to be asked about why this claimant was not able to work light duty when it was promised early-on in the file. Certain carriers will provide discounted premiums based on the existence and use of light duty return to work programs, and if the employer is not delivering on their end of the deal, expect premiums to increase.
It will also create a rift between the worker and their employer. Why was this person singled out to sit at home when others were allowed to return to light duty and make their normal wage? It is almost as if you are penalizing this worker, for whatever reason.
Implement Your Return to Work Program Consistently and Communicate, Communicate, Communicate
At the end of the day, the employer has the option to do what they want with each worker. But the program has to be clear, and applicable to all employees regardless of the injury or surgery that was performed. If you have a light duty program, use it for all of your injured workers fairly. If for whatever reason any particular worker will not be able to return to light duty, make sure the adjuster knows way ahead of time so they can plan other work options accordingly.
Per usual, it all comes down to communication.
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 founder & lead trainer of Amaxx Workers’ Comp Training Center .
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