Workers Comp Claims Archives - Work Comp Roundup

Common Mistakes That Get Employers In Trouble on Questionable Claims

January 29, 2013 by Rebecca Shafer, J.D. Leave a Comment

Employers Should Take the High Road

Every self-insured employer has to contend with the occasional workers’ compensation claim the employer feels is of questionable validity. The urge is often to ‘fight fire with fire’. However great the urge is to give the employee ‘a taste of his own medicine’, the employer must hold itself above taking the low road taken by the employee. Just as there are laws in every state against insurance fraud, there are also laws in every state that have names such as “unfair claim settlement practices”.

Unfair claim practices are any action taken by the self-insured employer that are unfair, discriminatory, deceptive or misrepresent the facts. Any inappropriate conduct by the self-insured employer can land the employer in legal trouble. In addition, if a particular unfair practice is shown to occur with any frequency, the insurance regulatory authority will review their approval of your self-insurance status.

Common Mistakes That Get Employers In Trouble

While there is a wide array of inappropriate actions a self-insured employer can get into trouble for, we will discuss only the most common mistakes an employer might make that would be classified as an unfair claims practice.

Delaying the processing of a claim – the self-insured employer cannot refuse to process the Employer’s First Report of Injury form or delay sending the required forms to the employee or the required forms to the state agency that oversees workers’ compensation.

Delaying the necessary investigation of the claim – most states require the claims office to accept or deny the claim within a specific period of time. If the claim is not accepted or denied timely, in most states the lack of a timely decision is acceptance of the claim. Worst yet, if the employer does not investigate the claim within the frame specified by the state, the employee’s version of the claim facts is accepted without any rebuttal by the employer.

Misrepresentation of coverage – the self-insured employer handling its own claims must provide the employee making an injury claim full information on available medical care and indemnity benefits, if indemnity benefits apply. For example: you cannot tell the employee there is a 30 day waiting period for indemnity benefits. Or, you cannot tell the employee that required medical services are not covered.

Withholding payment of benefits – the self-insured employer which has accepted a claim, or has received an adverse ruling on a claim, cannot withhold payment of temporary total disability benefits or the payment of medical bills in an effort to coerce a quick settlement with the employee.
Needless duplications – the self-insured employer cannot bombard the injured employee with extra or duplicate claim forms, or have the employee repeat medical procedures that were completed properly.

Withholding an equitable settlement – if the workers’ compensation regulatory authority has ruled that workers’ compensation coverage must be provided, the employer cannot refuse to make a good faith effort to reach a prompt and fair settlement of the claim, regardless of how the employer views the validity of the claim.

Appealing all awards – the self-insured employer cannot make it a standard business practice to appeal all awards of workers’ compensation coverage in an effort to compel employees to settle for less than they would otherwise be entitled to.

Putting forth an unreasonable settlement offer – the employer cannot offer to settle a workers’ compensation claim for permanent partial disability or permanent total disability for less than the requirements of the state statutes. The settlement offer must be based on the requirements of the law.

Unfair Claims Practices Acts Designed to Protect Employer & Employee

The unfair claims practices acts are not designed to compel a self-insured employer to pay fraudulent workers’ compensation claims. The unfair claims practices act statutes are structured to compel the self-insured employer to investigate thoroughly all claims. These statutes mandate the employer to either accept an employee’s work comp claim or to provide the reasons and the documentation as to why the work comp claim is not owed.

When the self-insured employer is confronted with the questionable claim, the employer should investigate the claim completely gathering all information from the employee, the co-workers, witnesses, medical providers, past employers, past medical providers, state agencies, the Insurance Services Office, and all other sources. A decision on the claim should be made timely and the decision should be conveyed to the employee and to the state agency.

By acting in an unbiased and factual manner, the self-insured employer will avoid any violation of the unfair claim settlement practices acts.

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com.

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional about workers comp issues.

Quite Possibily The Worst Workers Comp Claim Handling Ever

September 19, 2012 by Rebecca Shafer, J.D. Leave a Comment

Candidate for the Worst Claim Handling Ever

A leading candidate for the worst claim handling everturned up in a workers compensation claim file audit. A third party administrator (TPA) was handling claims for a statewide government self-insurance pool. And yes, all of the following mistakes were on one file!

Coverage

The TPA adjuster, upon receiving the claim, went to verify coverage. The coverage had expired twelve days before the claim was reported. The date of loss was five days after the coverage expired. The adjuster wrote in the file notes that he would confirm coverage before making any payments.” However, before the adjuster had done so, the TPA switched adjusters and the coverage question was forgotten.

Mistake #1. Handling the claim before coverage was verified.

The lack of coverage wasn’t addressed again until the pool’s executive director contacted the adjuster over a year later. By then over $65,000 had been paid on medical and indemnity by the TPA from the pool’s trust fund. There was no coverage but the pool was in an estoppel situation, so the TPA continued to cover the claim.

Mistake #2. The second adjuster not reading the first adjuster’s file notes.(WCx)

Contacts

Best Practices for a TPA include making contact with the employer, the employee and the medical provider within 24 hours. The TPA had overloaded its workers comp adjusters with over 200 files each. The government pool’s contract did not contain any provision for the maximum number of claims to be assigned to an adjuster. The second adjuster on the file never even saw the claim during the first three months it was assigned.

Mistake #3. Not reviewing the file when it was assigned.

Mistake #4. Timely contacts with the involved parties were not made.

Self Insured Mistake: Not having a contract stipulation on how many files could be assigned to one adjuster.

Investigation

Since the second adjuster never contacted the insured, the claimant or the medical provider, there was no investigation of the claim. The Employer’s First Report of Injury reflected that “the employee (a painter) hurt her lower back when she tried to move a five-gallon bucket of paint.”

Mistake #5. No investigation of the claim.

Medical Handling

File note entries read “Received medical bill” or “Paid medical bill” with the name of the medical provider and the bill amount. One medical report summarized in the file notes stated, “employee continues to work with her low back pain and wrist pain.” Three months into the claim a medical report stated “will need to do bilateral CTS (carpal tunnel syndrome) surgery.”

Mistake#6. Not comparing medical reports with the reported injury on the claim.

The employee was an obese woman with diabetes – two factors that can bring on CTS without an injury. Even though the claim was reported as a back injury, at no time did the adjuster question the carpal tunnel syndrome treatment.

Mistake #7. Failure to separate a covered injury from other medical conditions of the employee.

Mistake #. Lack of medical knowledge that CTS is not always injury related.

Mistake #9. Failure to get a medical termination based on whether the CTS was work related. If it was it should have been handled as a separate claim.

Indemnity Handling

The first contact with the employee occurred over four months into the claim when the employee called the adjuster inquiring about when she would be paid for her Temporary Total Disability, as she was off work due to the right wrist Carpal Tunnel Syndrome surgery (the left wrist would be done a couple months later). The adjuster did not follow up on the Temporary Total Disability question and got another phone call from the employee. The first contact with the employer occurred almost five months into the claim when the adjuster asked the employer for a wage statement.

Mistake #10. No on-going contacts with the employee and the employer.

Mistake #11. Not obtaining the wage statement from the employer when it was first noted the employee was going to need CTS surgery.

The adjuster put the temporary total disability (TTD) checks on autopilot and forgot about them. After about six months, the employee returned to work. As the adjuster had not been in contact with the employee or the employer, the Temporary Total Disability checks just kept on going out. The adjuster did not know the employee was back to work until receiving medical reports stating that the employee was at maximum medical improvement on her wrists and had been given a 15% impairment rating for both wrists combined. The employee received an extra eight weeks of Temporary Total Disability after she was back at work. The adjuster stated in the claim file notes that the overpayment of Temporary Total Disability would be taken out of the permanent partial disability (PPD) settlement. However, it never was recovered.

Mistake #12.Not making any effort to get the employee back to work earlier or to return to work on light duty.

Mistake #13. Putting Temporary Total Disability checks on long-term automatic issue. (WCx)

Remember the low back pain?

The employee had only been back to work for two months when the adjuster contacted her about the overpayment of Temporary Total Disability and settlement of the Permanent Partial Disability claim. The employee advised the adjuster that her back still hurt and she needed to go to the doctor. The doctor ordered an MRI of the low back. The employee had a herniated disc at L4-L5 and a partially herniated disc at L5-S1. The doctor scheduled surgery for the employee.

Mistake #15. Not having inquired about the lack of medical treatment on the low back for almost a year.

The adjuster, finally paying attention, refused to approve the surgery until an independent medical evaluation (IME) could be completed. The IME confirmed the need for the surgery. After the surgery, the employee was off work for another seven months before the doctor placed her at maximum medical improvement with a 25% rating.

Mistake #16. Not making any effort to get the employee back to work earlier or to return to work on light duty.

Negotiations

The adjuster contacted the employee with an offer to settle both of her Permanent Partial Disability ratings based on her being 40% disabled. The employee argued that she should be considered 100% disabled as she was not able to go back to her job as a painter. The adjuster refused to consider the claimant as having permanent total disability (PTD). A week later, the adjuster received a letter of representation from the employee’s new attorney, who claimed the employee was PTD. The attorney requested an administrative law judge (ALJ) hearing. The ALJ reviewed all the medical records and agreed with the adjuster’s defense attorney. The employee’s attorney appealed. The Workers Comp Board (WCB) agreed with the defense attorney. The adjuster paid the 40% PPD rating.

Worsening of Condition

A year later the employee’s attorney contacted the claims office, but the second adjuster was no longer with the TPA. A third adjuster on the claim learned that the attorney filed a request for the WCB to consider a “worsening of condition.”

Index Search

The new (third) adjuster looks over the file and realized that an ISO Index had never been filed on the claim. Once the index was filed, it was discovered that the employee had a prior back injury claim eight years before this claim. The employee was represented by the same attorney for both claims. The prior insurance company already classified the employee as 10% Permanant Partial Disability for a non-operated herniated disc. The prior medical reports showed that the employee’s earlier claim was for an L4-L5 herniated disc – the same injury the claimant had surgery for in this claim.

Mistake #17. Failure to index the claimant resulted in the TPA/pool paying for a claim that should have never been paid.

Exacerbation vs. New Claim

It was now obvious that the present injury was not a new claim, but the exacerbation of an old claim. If the index had been done when the claim first was received, it could have been referred back to the prior insurance carrier. The defense attorney requested that the ALJ transfer the claim back to the original insurance company. This is after the TPA had already paid the employee a 40% award (15% wrist and 25% back) on top of the 10% award the employee had received for the earlier claim.

The ALJ stated that as the TPA had already accepted the injury as a new claim, it would not change it now. The WCB appeal was denied, so the current insurer was stuck paying for the claim although it was an exacerbation of a preexisting injury.

Back to the Medical

The employee’s disk fusion surgery had failed. The treating doctor recommended another surgery. The third adjuster was too inexperienced to be handling this type of claim.

Self Insured Mistake. Not having a stipulation in the contract requiring experienced adjusters to handle claims -especially high dollar ones.

The adjuster asked her supervisor what to do. The supervisor said to get another IME. The IME stated that the fusion had partially failed, but absolutely did not recommend another surgery.

Sympathy

The attorney gave the third adjuster a sad tale of how much pain the employee was in, that the employee’s marriage was falling apart due to her pain and she was desperate to have the surgery. The attorney played on the adjuster’s sympathy until the adjuster agreed to the surgery.

Mistake #18. Allowing emotions instead of medical facts to make the determination on how to proceed on a claim.

The adjuster should have had denied the additional surgery and forced the employee’s attorney to have the ALJ or even the WCB make the determination.

Permanent Total Disability Granted

Following the second surgery, the employee’s attorney filed a petition for PTD. The treating physician had given the employee a total 75% Permanent Partial Disability rating based on the bilateral CTS surgeries and the two back surgeries. The defense attorney arranged another IME and got a similar rating of 65% total. The ALJ looked at the total medical history and the employee’s 65% or 75% permanent partial disability rating following her two wrist surgeries and her two back surgeries. The ALJ gave the employee a PTD finding. The defense attorney appealed to the WCB. The WCB agreed with the ALJ and the third adjuster paid the employee another 50% rating. (WCx)

Summary

The failure to do the simple things in the claim file handling resulted in the self-insured pool paying out over a half million dollars in medical, indemnity and legal expenses. Verification of coverage would have stopped this claim before any dollars were spent. A proper investigation at the start of the claim, including an index of the employee, would have shown that the low back claim was an exacerbation of a prior injury and would have eliminated that portion of the claim. The review of the medical reports would have resulted in a denial of the CTS or at least had it treated as a separate claim. Non-compliance with Best Practices changed what should have been zero dollars paid into a PTD claim.

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact: RShafer@ReduceYourWorkersComp.com.

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com.

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Claim Management Tagged With: Claim Management, Claims Handling, Claims Resolution and Settlement, Indemnity Benefits & Claims, Managing Claims, Settling WC Claims, TPA and Claims Administration, Workers Comp Claims

Legal Pad vs. iPad, How Workers Comp Claims Handling Has Changed

August 17, 2012 by Rebecca Shafer, J.D. Leave a Comment

Two Big Changes in Claims Handling

20-30 years ago, a claims adjuster used to investigate claims a lot differently than they do today. Back then, adjusters were given legal pads, a tape recorder, a pen, a company car, and a list of their claims. Some say that the technological trend we live in today has negatively affected the art of investigation for injury claims. But how? And what is so different today when compared to 30 years ago? The answer to this is subject to argument, but there are a lot of clear differences when you compare today’s insurance adjuster to the one of yesteryear. Here are the pros and cons on the two biggest changes in the way claims are handled below:

Field adjusters versus in-office claims adjusters

Back in the day, adjusters always did in-person statements. This entailed going to the employer or house of the claimant and taking their statement along with gathering their pertinent information, and putting paper notes in a manila folder which consisted of the actual claim forms and information. [WCx]

Field Adjusters Meet You Face-Face

In the past, if you are the adjuster and you are sitting across from the claimant, it could be considered more difficult for the claimant to distort the injury or accident details when recalling what happened. In fact, seeing your claimant in their actual home environment was considered a good way of “sizing them up” when it came to their complaints of injury and how their actual behavior and activities of daily living were affected. Since you are right there, you can look around the house and see what is actually going on. Is the house neat and tidy? Is the claimant wincing in pain or finding it difficult to sit still? Does your injured worker have dirty fingernails which show they may be doing activities more strenuous than what they are telling their doctor they can do? Do they have a good family support system present to help them in their time of need or to tend to their daily tasks? The answers to these questions could affect the outcome of the claim, and what the future could hold for where the claim is going to go in the future.

Today Adjusters Work Almost Exclusively by Phone

Today, the role of a field adjuster is about gone. Some insurance carriers still have field adjusters to do accident investigations and so on, but it is nowhere near the capacity that it used to be. Claimants can “hide behind their phone” and essentially make any allegation they want, since they do not have to put on an act with their adjuster sitting right there.

Since the claimant rarely if ever sees their actual adjuster, a personal relationship is really not made, be it positive or negative. By keeping the adjuster in an office, the carrier eliminated large overhead costs with company vehicles, drive time, mileage, and so on. This also allows the adjuster to carry a larger caseload. Since they are chained to the office they are capable of handling a lot more than someone who is on the road. This again can be seen as a positive or negative. The point is that the actual in-person investigation that all adjusters used to do is no longer a factor. Whether or not this is a negative in regards to the actual investigation is tough to prove. Adjusters nowadays have had hours of training about how to interview, and what verbal and nonverbal cues to pick up on when they are talking to their injured parties. There is more in-depth training involved now than there used to be years ago, both in investigation tactics and in medical terminology training. So the difference really lies in the adjuster, and how good they are at doing their job. There were good adjusters and bad adjusters 20 years ago, and there are good adjusters and bad adjusters now. [WCx]

“Start to Finish” claims handling versus ascending levels of adjusters

In the past, adjusters were assigned to certain employers or insurance agencies, and that sole adjuster was the one to handle claims from either of those two parties. Not only did they get every claim those parties produced, but the adjuster of the past handled those claims from start to finish no matter what the level of severity. This lead to the adjuster forming a great relationship with those agencies or employers, and several positives came of this relationship. The adjuster knew an employer in and out, toured their facility and knew the job tasks demanded of their workers. The adjuster knew a lot more about the employer than the injured worker may think they knew.

Pro of Single Adjuster is Level of Employer Knowledge

If the adjuster knows the job titles, responsibilities, layout of the floor, the risk managers, and the executive staff, then an in-depth relationship is made, and it is hard to put a price on that. A single adjuster could be saving this employer a lot in insurance expense and premium cost, just by the simple fact that the adjuster knows the employer’s demands and what goes on at this employer on a daily basis.

Nowadays, it may be considered a luxury if the adjuster that handles your claims is even in the same state as the employer. Out of state adjusters miss out on local politics, stereotypes of local doctors and clinics, and the overall work ethic of people in one city versus another. Even more disconcerting, the adjusters start to bounce files to other adjusters in other states depending on the financial exposure or reserves allocated by the carrier.

Con is Unspecialized Claim Experience

This can be considered a pro or con. If one adjuster specializes in severe injuries, and you incur a severe injury for a comp claim, then it would make sense that you want that adjuster to handle the file versus the entry-level adjuster who doesn’t have the experience or background in dealing with severe injuries. But, negative issues can come attached to those carriers who bounce claims around, namely the main issue that this new adjuster has not handled the claim in the very beginning. A lot can go on early in a claim, and every adjuster has their own style of claims handling in general. So what if some factors were missed early on that could affect the outcome of the claim? What if certain questions were not asked that could have affected the compensability of the claim, had they been asked the day after the injury versus being asked months later?

This is what can frustrates claimants the most. Just when they get comfortable and start to trust the first adjuster, their file is moved to another adjuster. They have to essentially repeat the whole process over again, possibly including taking another statement and trying to form another relationship with this new adjuster. Maybe this new adjuster doesn’t return calls as quickly as the first adjuster. Maybe the new adjuster is not as verbose as the first adjuster, and the claimant feels that this new adjuster is not paying them the attention they feel they were paid before. Whatever the case may be, there are again pros and cons to each argument about which way is best.

Summary

These two issues have only scratched the surface between how claims are handled now versus how they were handled 20-30 years ago. Which way is better is best left up to the parties having this discussion. As you can see, even with these two changes, it can open the door to hours of discussion. The fact is that it is 2012, and with the technological advances that have been made, both in the insurance industry and in industry in general, we have to adapt to these changes and provide what we think will be the best info to help the adjuster make the proper decisions handing their claims.

Let’s face it, claims are not going anywhere. How we handle those claims is a constantly changing atmosphere, and you have to adapt to change.

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Claim Management Tagged With: Claim Management, Claim Reporting, Claims adjuster, Claims Handling, Managing Claims, Reporting Claims, Workers Comp Claims

Not So Fast – Get All The Facts Before Accepting a Workers Comp Claim

July 6, 2012 by Rebecca Shafer, J.D. Leave a Comment

Sometimes when an occupational injury occurs, it seems like a no-brainer that it would be an accepted workers comp claim. The question often comes up when an acute injury occurs if the employer should ok the claim, even though there may not be details or information right at hand? The investigation that the adjuster performs can take several days to complete, if not longer, depending on the extent of the injury.

The idea of accepting a claim without prejudice will occur in certain jurisdictions more than others. It all depends on how the comp act is read within the jurisdiction where the workplace is located. Here are a few things to look out for:

1. The injury seems to be acute

If a worker drops a 50lb piece of equipment on their foot and falls to the ground in pain, it is quite obvious medical attention is needed. Chances are this claim will be accepted as compensable without any major issues. It is possible that safety protocol may be to blame for the incident, but any defenses as an adjuster will depend on the jurisdictional statutes. Even in the most conservative states, the bottom line is if the worker is in the course and scope of employment and doing a duty that is of benefit to the employer, the claim is compensable. It maybe safe in this example to say the adjuster would OK the claim based on merit alone, but this is not always the case. The fact of the who, what, where, when, why, and how the injury happened may come into play later on in the claim which could lead to a suspension of benefits, or an overall denial.[WCx]

2. The injury is witnessed

A lot of workers are under the belief that just because someone directly saw the injury happen it means claim will be compensable. This is not always the case. It helps to validate the claim, but that does not make it pass the criteria to make it compensable. I am not aware of workers comp laws in any state that directly say “If any injury were to be witnessed it is automatically compensable.” A witness statement has to be applied and the validity of the claim determined on a case by case basis when it comes to overall compensability.

3. The worker sustains a hernia, or herniated disc. Does that make it automatically compensable?

Of course it does not. If there are 50 people randomly selected out of the general public of varying age, a good percentage of those people may have disc problems, or umbilical hernias, that may or may not cause any noticeable medical problems. The diagnosis of a hernia or herniated disc makes adjusters cringe, because there will now be a complex claim that will require a lot of medical investigation, and a lot of work to gather evidence to show why or why not that particular diagnoses is or is not occupational in nature.

4. Investigation on the employer’s side of the claim points to the claim being compensable, so does that make it compensable?

No it does not. The employer’s investigation and opinion is only one aspect of the claim. There is still the employee’s story, the story of the involved witnesses, the medical story, and the legal support of the claim. All of these involved parties and the overall completion of the investigation of the claim will tell the story about if the claim will be accepted or not.

Sometimes there are claims where the employer’s investigation and the statement made by the employee point to potential compensability, but the medical aspect does not add up. Remember, all of the prongs of the investigation have to point to the claim arising out of the course and scope of employment and arising out of the course and scope of the injury occurring within the stated job duties that the employee was to be performing at the time of injury. If one of the aspects of the claim does not jive with the rest of the claim, the adjuster will file a dispute or suspension with the State in order to try and tie the case together.

In the end, the burden of proof lies on the clamant to show how and why the injury occurred, and how and why that arose out of the course and scope of their employment. The adjuster is not going to go out of their way to try and prove the case for the claimant. No one aspect of the claim can outweigh the other ones; they all have to correlate without conflict. It is only then when a claim will be accepted as compensable. .[WCx]

Summary

The aspect of accepting a claim without prejudice is a risky one. An adjuster cannot accept a claim as compensable based on just one part of the investigation, or the presence of a certain diagnosis. The carrier has the right to stop or suspend benefits and coverage whenever coming across some evidence that may be contrary to what is currently known to be the details of the injury and how/why it occurred. The safe bet is to complete as thorough an investigation as possible, on all prongs of the case. Those prongs being on the employer’s side, on the carrier’s side, on the medical evidence, and on the applicable legal statutes within the jurisdiction that has coverage.

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com

VIEW SAMPLES PAGES

MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Claim Management, TPA and Claims Administration Tagged With: Prejudice, Work Comp Compensability, Workers Comp Claims, Workers Comp Compensability

You Need to Handle Workers Comp Claims This Way

June 12, 2012 by Rebecca Shafer, J.D. Leave a Comment

While every workers compensation claim is unique, every claim contains certain key events and documents. The Best Practices established by either the insurer or the third party administrator will create a certain amount of uniformity in the claims.

When reviewing workers comp claims of employees there needs to be an established criteria in the handling of the claims. Each claim will contain information on: [WCx]

Coverage

Contacts

Investigation

File Documents

Evaluation and Settlement

Coverage

The very first step the adjuster will take in the handling of the claim is verifying there is coverage. This includes checking the policy number to be sure it is accurate; the policy dates to be sure the injury occurred during the time frame covered; the state(s) covered by the policy; and, any endorsements to the policy or exclusions of coverage. If any aspect of the coverage verification is missing, the adjuster should stop any further activity on the file until there is proof the insurance covers the claim.

Contacts

Once the workers comp adjuster has verified there is insurance coverage in effect for the name insured, on the date of the injury, and in a location covered by the policy, the adjuster will contact all the involved parties. Whether the adjuster contacts the injured employee or employer first will depend on the nature and extent of the injury, as well as time frame of the known events. The adjuster will also contact the medical provider’s office to obtain the initial medical treatment information, provide information to the medical provider on billing for their services, and provide the medical provider with information on the return to work policy of the employer. Any other parties that may impact the claim will also be contacted. For example, witnesses on questionable or severe claims.

Investigation

Contact with all parties involved is the start of the claim investigation, but proper investigation will contain many other actions that will impact the future outcome of the claim. Some of the investigation steps include:

A comparison of the details of the accident as provided by the employer, the employee, the medical provider and any witnesses. Any deviation in the information obtained from the various parties will need to be analyzed by the adjuster.

The filing of the Insurance Service Office inquiry to determine if the employee has made prior insurance claims, and if so, do they impact the present workers’ comp claim. For instance – the employee who strained his lower back in your claim, also had a lower back injury work comp claim with a previous employer.

A determination if there is a third party responsible for the employee’s injury, and if so, the documentation needed to pursue a subrogation claim.

An analysis of the nature and extent of the employee’s injury, the medical treatment plan and the prognosis for the employee’s recovery.

An analysis of the employee’s job duties, equipment used, the return to work restrictions from the medical provider and the modified duty information obtained from the employer to determine if a modified duty job is an option.

A determination as to the future course of activity needed on the file, also known as an Action Plan.

File Documents

Every claim file will have basic claim documents to support the claim and the activity. Depending on the extent of the injury, the file may have additional documentation that might not be found in a simple injury claim. The documents you may see in the claim file include:

The Employer’s First Report of Injury

The recorded statement summary of the employee and possibly the recorded statement summary of the employee’s supervisor and/or witnesses.

The required state forms filed with the governmental office enforcing the workers’ compensation statutes of the state.

The wage statement showing the employee’s earnings during the required calculation period.

The Insurance Service Office report.

The medical records.

Vocational and/or rehabilitation reports.

Subrogation documentation.

Correspondence to and from defense counsel, correspondence to and from the employee’s attorney, and correspondence between defense counsel and the employee’s attorney.

Reserve worksheets used to calculate the cost of the claim.

File notes (a log of activities undertaken) making a record of every telephone call, piece of mail, e-mail, fax or other communication on the claim.

Evaluation and Settlement

When the claim file has progressed to the point where the adjuster can start the evaluation process (usually when the employee has reached maximum medical improvement); there will be either a reserve worksheet or an evaluation worksheet establishing the financial exposure of the claim. The evaluation of the claim will include the compensability, the disability rating, the jurisdictional law and any legal questions that need to be resolved. The file notes should describe the adjuster’s settlement discussions when they have taken place. [WCx]

An essential part of risk management is to know as much as possible about the exposures your company faces. We recommend that you obtain electronic access (on a read-only basis) to the insurer’s or third party administrator’s claim file. By knowing what is in your claim file, you will able to contribute any additional information that will benefit the adjuster in bringing your employee’s workers comp claim to a conclusion.

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Claim Management Tagged With: Claims Handling, workers comp adjuster, Workers Comp Claims

Make Sure Your Carrier Does Not Use Trapdoor Communications

April 1, 2012 by Attorney Theodore Ronca Leave a Comment

Communication (a sharing of information) is essential to proper handling of workers comp claims. Workers comp has a complicated communication network which, moreover, operates with numerous time deadlines. Regulars in the field, especially attorneys and doctors, quickly learn to spot the pitfalls and work through, under, over and around them.

But what about your employees? Chances are, they trust and hope much, and imagine that the vast communication network on claims is forwarding the proper information to the right people. Perhaps the employer thinks the same. [WCx]

It might come as a shock to learn that some communication is far from being an effective exchange. It is, in fact, a one-way flow to the detriment of the unwary. This form of communication, which takes information from the worker, gives nothing back, and only stores what is detrimental to the claim, discarding nearly everything else, appeared about ten years ago.

A call is made to a carrier. When the caller is identified as a person with an interest in a claim the call is transferred to a person vaguely identified as a “claim resolution officer” or, perhaps, not identified at all. The caller is asked some of the usual questions but then is asked if there are any problems. If the caller asks any questions, they will go unanswered, with a variety of reasons given. In the end, the caller is referred to a different number, or told to write.

What has occurred is that the caller, without realizing it, has been involved in a recorded call, after which the call may, or may not be saved. A warning is given that the message may be recorded “to ensure proper handling”.

In fact, the person on the other end may have a law degree, but is not admitted yet as a lawyer. Normally, a lawyer who is admitted is required to advise callers that they are speaking to a lawyer. But a person not admitted does not have to mention that they have a law degree. The person taking the call has, in fact, received training in asking the proper questions, but providing no answers. Calls which are useful for the carrier are saved. Others are dropped.

If this sounds a bit over the top, it is. Fortunately, it appears to be rare.

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How can we be sure that this was, or is, going on? When lawyers began having such strange conversations with claims units, the professional tendency toward paranoia got the better of them and searches on the Internet were conducted. Several years ago, an on-line ad for new law grads “not yet admitted” to work as “claim resolution specialists” appeared, posted by a major company.

And any trial lawyer knows in a nano-second when they are speaking to a law grad.

The practice seems to have shrunk since then. Workers, as any lawyer can tell you, have rather acute senses when it comes to strangers asking even stranger questions. But the biggest brakes seem to have been the law grads themselves. Recent law grads have the zeal and optimism of newly ordained missionaries and do not adjust well to a job better suited to the most cynical private investigators. In addition, the grads were themselves not told precisely what would be involved. When the truth appeared, the job was seen to be a resume killer. [WCx]

Hopefully, the practice has ceased. But employers should take the trouble to ask the employees what sort of treatment they are getting from the carrier.

Author: Attorney Theodore Ronca is a practicing lawyer from Aquebogue, NY. He is a frequent writer and speaker, and has represented employers in the areas of workers’ compensation, Social Security disability, employee disability plans and subrogation for over 30 years. Attorney Ronca can be reached at 631-722-2100. medsearch7@optonline.net

WORKERS COMP MANAGEMENT MANUAL: www.WCManual.com
MODIFIED DUTY CALCULATOR: www.LowerWC.com/transitional-duty-cost-calculator.php

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

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Filed Under: Claim Management, Communication with Employees, NY Workers Comp Issues, TPA and Claims Administration Tagged With: Trapdoor Communications, Workers Comp Claims, Workers Comp Communication

Top 5 Ways Employers Push Injured Workers to Attorneys

June 8, 2011 by Rebecca Shafer, J.D. Leave a Comment

As long as there are workers compensation claims and ways for attorneys to make money from workers comp claims, attorneys will be involved in the processing of some of these claims. There will always be employees enticed by television commercials with the attorney holding fistfuls of money and saying, “Call me. I will make you rich.” or words to that effect.

Employers cannot do much about the greed factor. However, they can do quite a lot to keep otherwise honest employees from hiring an attorney. When employees hire attorneys, the cost of workers compensation goes up as the attorneys seek to maximize both the employees’ and their own financial well being. (WCxKit)

There are three primary reasons employees hire an attorney in the workers comp claim process. The employee (1) does not know what to expect; (2) is fearful for themselves and their families; (3) a controversy develops between the employee and the employer, or between the employee and the claims adjuster. Of course when the employee’s attorney files a petition with the workers compensation commission, they do not list “greed” as the reason; rather, they attempt to cloak the greed by creating controversy.

To significantly reduce the number of employees hiring an attorney avoid making these five mistakes driving an employee into the arms of a waiting workers comp attorney.

Failing to Provide Immediate Medical Care

Being lazy about providing medical care to the injured employee is one of the biggest mistakes an employer makes when an employee is hurt. When an unknowing or untrained supervisor does not want to bother with the workers comp claim and tells the employee to “give it a few days,” it is almost a guarantee the employee is going to hire an attorney.

Think! — The employee is in pain, medical care is not being provided, the employee’s attitude quickly becomes “they don’t care about me” which quickly switches to “I don’t care about them either.” The only remaining question for the employee is whether to go to a doctor on their own or not. To answer that question they turn to the Internet/TV attorney or the yellow pages attorney. Keep in mind these cases are taken on contingency so the injured worker does not have to come up with a retainer for attorney fees. If the employee “wins” the case, the employer pays the attorney.

The solution – Everyone in the company, including employees, should know immediate medical care is to be provided on all work-related injuries. Every supervisor and manager must ensure medical care is provided immediately upon learning an injury occurred. Of course, if your company used nurse triage, this would go a long way toward allevaiting this issue because employees would call the triage nurse immediately.

Late Reporting

It is always amazing to workers comp adjusters, defense attorneys, and the Board of Workers Compensation when they see an injury occurred a week ago, a month ago or even longer before it is first reported.

Sure, the time and paper work of reporting a workers comp claim is a hassle, and the employer’s person(s) in charge of reporting workers comp claims has more important things to do (like office gossip time, personal e-mails, or even actual work responsibilities). However, as the employee sits at home not hearing from the workers comp adjuster, medical triage or the employer, fear sets in and questions arise about how bills are going to be paid and the family taken care of. When no one explains how much the indemnity check will be, or consults about medical care, (since no one reported the claim to the claims office) the employee starts to think about hiring an attorney to enforce “their rights.”

The solution – The person(s) in charge of reporting claims to the claims office must consider the immediate reporting of the claim as THE number one priority over all other job responsibilities.

Ignoring the Employee

After the supervisor obtains immediate medical care for the employee and the claim is reported on the same day to the claims office, the employer must continue to be involved in the claim. If the employer “forgets” the employee works for them after the claim is reported to the claims office, the employee will develop the attitude that the employer no longer cares about them, and then seeks out an attorney. The attorney is then the one who patiently listens to the employee’s tale of woe and assures them “everything will be okay.”

The solution – Instead of paying an attorney to reassure the employee, the employer should do so. Whether it is the claims coordinator, the employee’s manager, or someone else within the company, a person representing the employer must maintain regular contact with the employee following the initial medical care and at regular intervals until the employee is back at work full duty. That means regular phone calls, meetings and get-well cards. Make a First Day Phone Call the evening after the injury to make sure all bases are covered. Consider using “Early Dissatisfaction Surveys”, a service Jennifer Christian, M.D. provides, to find out how your employees are treated when they are injured.

Under-reporting the Compensation

Regardless of how state laws require temporary total disability compensation to be calculated (13, 26 or 52 weeks) the average weekly wage includes all compensation, often more than the amount of salary or wages paid each week. If the employee normally receives commissions and bonuses, or is provided housing, meals, or paid health care benefits, include all types of compensation in your report of income to the claims office. When the employee sees the indemnity check does not include the bonus, commissions or health insurance coverage, these omissions can become a reason to seek out an attorney to obtain all due benefits.

The solution – know your state law and what should be included in the calculation of indemnity benefits. If some type of benefit you have been paying to or for the employee is not included in the compensation reported to the insurance company, then it needs to be discussed with the employee so the employee knows why they are not receiving that part of the compensation.

Not Complying with the Medical Restrictions on Modified Duty

Too many employers willingly accept the employee back at work on modified duty status from the treating doctor, and put the employee right back to work doing the previous job. If the doctor states the employee cannot lift more than 10 pounds, and you assign the same job duties where 40 pound lifting was routine, expect problems. First, you are going to re-injure the employee and extend both the medical treatment and the time off work, plus you are going to create that “they don’t care about me” attitude with the employee.

The solution – Review the modified duty restrictions imposed by the treating doctor and know exactly what the doctor expects in the way of modified duty. During the first minutes the employee is back at work on modified duty, review what the doctor states can and cannot be done, keeping modified duty in compliance with the doctor’s restrictions. (WCxKit)

By treating the employee properly, you can expect to lose fewer employees to attorney representation and the associated cost of attorney involvement. Plus, you will have a happier and more productive employee as the employee understands you care.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com

Our WC Manual: http://corner.advisen.com/partners_wctoolkit_book.html

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Communication with Employees, Litigation Management Tagged With: Legal Representation, Workers Comp Claims

Saskatchewan Adds Cancer to Coverage

May 15, 2011 by Robert Elliott, J.D. Leave a Comment

The Saskatchewan government is adding esophageal cancer to the list of cancers considered occupational diseases for the province's full-time, professional firefighters.

Workplace Safety Minister Don Morgan says the amendment to the Workers Compensation Act signals the government's intent to cover risks posed by toxins, carcinogens and cancer-causing agents in the daily work of firefighters. (WCxKit)

There will be a minimum employment requirement period. No incremental costs to the Workers Compensation Board are expected with this legislation, since esophageal cancer claims are already accepted by the board if there is sufficient evidence establishing a causal link to the work performed.

There are close to 700 full-time, professional fire fighters in Saskatchewan.

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact:Info@ReduceYourWorkersComp.com or 860-553-6604.

Our WC Manual: http://corner.advisen.com/partners_wctoolkit_book.html

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SUBSCRIBE: Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Canada Workers Comp, Legal Doctrines, Medical Issues, Settling WC Claims, WC in Other Countries (International) Tagged With: Canada Workers Compensation, Canadian OH&S, Cancer, Legislation and Workers Comp, Medical Issues, North Carolina Work Comp Law, Saskatchewan WCB, volunteer firefighters, Workers Comp Claims

Death While Attending Leadership Conference Was In Scope of Employment

April 4, 2011 by Robert Elliott, J.D. Leave a Comment

A Texas appeals court has ruled that a landscape manager was within the “course and scope of his employment” when he passed away en route to pick up a co-worker to attend a leadership conference

The recent ruling by the 3rd District Court of Appeals in Texas in Zurich American Insurance Co. vs. Chantal McVey upholds a lower courts decision denying Zurich's argument that Troy McVey's beneficiary was not entitled to workers compensation benefits due to the fact he was not acting in the course and scope of his job when he died in an auto accident.(WCxKit)

According to Business Insurance, on the day of the accident, McVey was behind the wheel of a company-owned truck he regularly used to perform his employment. He was scheduled to attend his employer's leadership conference and was slated to pick up the co-worker, who also was required to attend the event and lived in proximity to McVey's route to the company gathering, according to court records.

Court records also report that the employer “emphasized policies that its employees should be efficient when making company-funded travel and made employees subject to dismissal for repeated perceived abuses.”

Zurich's arguments were directed toward the belief that McVey essentially was engaged in “an everyday trip to work,” according to court records.

But the appeals court found that a “coming-and-going” rule that prohibits benefits for accidents while traveling to work does not apply in this case.(WCxKit)

It said McVey was taking part in travel that furthered his employers business. As a result, his death is compensable, the court concluded, according to BusinessInsurance.com

Note: The facts of each "coming and going" case are slightly different even though many may appear to be the same. Make sure to ask your local defense counsel and the insurance company if your employees were "coming or going" to work.

WC IQ TEST: http://www.workerscompkit.com/intro/

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SUBSCRIBE: Workers Comp Resource Center Newsletter

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Legal Doctrines Tagged With: Death Benefits, Legal Issues, Medical Issues, Settling WC Claims, Texas Workers Comp Issues, The "coming and going" Rule, Workers Comp Claims

Terminated Employee TTD Benefits for Carpal Tunnel Reinstated

October 23, 2010 by Rebecca Shafer, J.D. Leave a Comment

A law mandating fired employees file workers compensation claims within six months of their termination is unconstitutional, according to an Oklahoma Supreme Court ruling in a case involving cumulative trauma. (WCxKit)

According to BusinessInsurance.com, a trial court in Ponca Iron & Metal Inc. vs. Jackie Wilkinson originally found that Wilkinson was entitled to medical care and up to one year of temporary total disability benefits starting in August 2006,

Wilkinson was fired in December 2005 from a job that included keyboard use and filing work.

A Workers Compensation Court upheld the trial court’s finding, but a Court of Civil Appeals reversed and remanded the case. On remand, the trial court turned down the employer’s argument that a six-month statute of limitations applied to the case.

The trial court stated that the statute of limitations in the law cited by the employer "unreasonably singles out employees who have been terminated and have sustained cumulative trauma injuries.”

The trial court also indicated the law is in direct conflict with a general, two-year statute of limitations for filing cumulative trauma injuries.

Oklahoma’s Legislature enacted the law cited by the employer to curtail fired workers from filing retaliatory workers comp claims, court records state.

In ruling on the case recently, the Oklahoma Supreme Court agreed that the state law is unconstitutional. It stated that “the classification of injured employees on the basis of continued vs. terminated employment is a false and deficient classification of the larger class of injured employees due to the fact it creates preference for members in the continued employment group and results in unequal treatment for certain members of the terminated group.” (WCxKit)

The temporary total disability benefits award was sustained.

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.
Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

Filed Under: Insurance Issues, Rates, Premiums, Legal Doctrines Tagged With: Oklahoma WC Law, When to File a Workers Comp Claim, Workers Comp Claims

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Not So Fast – Get All The Facts Before Accepting a Workers Comp Claim

You Need to Handle Workers Comp Claims This Way

Make Sure Your Carrier Does Not Use Trapdoor Communications

Top 5 Ways Employers Push Injured Workers to Attorneys

Saskatchewan Adds Cancer to Coverage

Death While Attending Leadership Conference Was In Scope of Employment

Terminated Employee TTD Benefits for Carpal Tunnel Reinstated

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