Many times when it comes to workers’ compensation claims, it may be easier for some adjusters to just pay the claim. After all, when it comes to your employees or the employees of your policyholders, you want a favorable outcome for both parties. But is a thorough enough job being done by adjusters with these claims?
In recent discussions with claims managers, there is a common concern regarding the effort that is put into investigating and handling of workers’ compensation claims. There is also a concern about the level of customer service they are experiencing, that is eroding their confidence with some adjusters.
Quality Counts
Claims and risk managers are looking for attention to quality in the handling of their workers’ compensation claims. When it’s obvious a claim was handled with a high level of quality, there is a higher level of confidence, whether the claim is approved or denied.
Let’s use the example of a workers’ compensation claim that was filed by an employee from a slip and fall in the employer’s parking lot. The employee fell and broke her ankle while walking from her car one morning on the way to a meeting.
To determine the compensability of this claim, it needs to be properly and thoroughly investigated. For starters, every adjuster needs to have the relevant experience and knowledge for some of the basics in this example:
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Every state has their own rules – which states does the adjuster have experience with?
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Extended Premises Doctrine – does this apply to this specific situation?
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Were there witnesses and were they interviewed?
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What were the weather conditions at the time of the accident?
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Who owns and maintains the premises?
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Was there is a dedicated place for the employee to park?
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Was there construction going on in the parking lot?
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Is there an opportunity for subrogation?
These are some of the basic areas an adjuster should be focused on to determine the compensability of this particular claim.
But what additional steps can the adjuster take to ensure a high level of quality was used to determine compensability?
Acting Immediately
Contact should be made by the adjuster within the first 24 hours or sooner and photos should be taken. If your adjuster cannot be onsite that quickly, get your human resources personnel involved to look where the incident occurred and take some pictures. Just about everyone has a smart phone with a camera these days. Too much can change by waiting just two or three days to make contact and document the scene.
Reviewing Video Footage
Video surveillance is common place these days for heightened security and has increasingly become part of the claim file. If available, reviewing video footage should be on the adjuster’s check list.
Thoroughly Understanding the Medical History
Is the claimant being properly questioned about their medical history? Did they recently visit their primary care physician or walk-in clinic prior to the FNOI and if so, are those records being reviewed? This also involves the adjuster following best practices when taking recorded statements as we discussed in a previous article.
For example, there was a case where someone claimed they twisted their ankle in the company parking lot upon arrival at work Monday morning and submitted a workers’ compensation claim. When reviewing records from the hospital, the adjuster discovered the injury occurred at a softball game during the prior weekend.
Attention to Details
For this particular example, weather conditions during the day and time the accident was reported to have occurred is important. How is the adjuster verifying the weather conditions?
In addition to using a simple Google search, sites such as www.wunderground.com provide very detailed information. In addition to temperature, humidity, visibility, and wind for a given day, the site provides events such as fog, thunderstorms for each day down to the hour. Did the freezing rain start at 7:00 am that Monday morning or was it 9:15 am?
Were maintenance records checked? Maybe an issue such as a pothole was reported to the party who owns or maintains the parking lot but never repaired?
Conclusion
Insurers don’t mind paying workers’ compensation claims that have been handled properly. The quality of how well the claim was handled, regardless if the claim was approved or denied, is what insurers expect from their adjusters.
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