When to Deny a Claim
When in doubt, deny, right? WRONG!
If there is doubt, it likely means that a proper claim investigation was not completed. It all starts with insurance carriers and third-party administrators in providing their insured clients with the proper tools to assist in injury investigation and claim to report. Now is the time to refocus program energies and implement strategies that work.
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Proper Injury Reporting is Key
Employers and their representatives are on the front line of proper injury report when an injury occurs. The investigation needs to start immediately after appropriate medical care and treatment is provided to an injured employee, and they are stabilized. Common elements of a proper work injury investigation include:
- Get all the important information. This includes the basics such as the employee’s name, date of birth, wage information, Social Security Number, and other background information.
- Injury information. This includes asking the important “reporter questions” – Who, What, When, Where, How, and Why. Getting the correct, and complete information is key
- Obtain the names of all witnesses. This information will assist the claim handler when investigating a claim. This is important in injuries that occur outside a place of employment such as a “traveling employee.”
Injury Reporting by Employers
Many employers and other insureds do not understand the mechanism of injury reporting to their instance carrier, or third-party administrator. This hinders the claims process, and can result in penalties for inaccurate or untimely injury reports. Proactive claim teams can take the following steps to assist in the claim reporting process:
- Provide quarterly training on workers’ compensation processes. This can include safety prevention information that allows human resources professionals and managers to understand the workers’ compensation process and what needs to be done following a work injury. It can also ensure the proper forms are submitted, and done so to the correct parties.
- Develop injury reporting platforms to assist in injury reporting and investigation. The fax machines are an outdated tool from the 1980s. Now is the time to move a claim program to a web-based system that includes the use of smartphone app technology. It ensures that forms are completed accurately and completely. It also allows anyone with a smartphone to take photos, record videos, and audio, and transmit on a secure platform.
- Provide contact information to all parties. It is essential that an injured employee is provided with contact information for the insureds workers’ compensation insurance carrier following a work injury. This allows the employee to have an immediate point of contact regarding their claim and ability to contact the claim team with questions on whether the claim is compensable, how to receive additional medical care and treatment, and the ability to address concerns regarding the process.
Understand the Mechanism of Injury
Famed criminal defense lawyer Johnnie Cochran once exclaims, “If the glove doesn’t fit, you must acquit.” In the same vein, a claim handler should only accept a claim if the evidence and claimed mechanism for injury fit the documented injury. Examples of this are numerous. This includes common scenarios such as:
- Whether the lifting motion claimed by the employee could cause a herniation in the employee’s low back disc;
- If constant twisting and turning of a lever could result in the employee’s rotator cuff tear; and
- If a certain motion, or movement could result in the claimed knee injury.
The important point to remember is that understanding these issues all starts with an effective investigation.
Conclusions
Effective claim investigation all starts with a claim team supporting their insured. This includes training, education, and tools to assist in a claim investigation and resources to accurately report the injury. A central point of contact should also be provided. If done correctly, only compensable claims will be accepted and paid.
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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.
