When it comes to workers’ compensation claim handling, quality investigation is the key. Employers expect quality work from their claims adjusters. If the adjuster does a thorough investigation and provides timely feedback and information regarding the claim, they will be satisfied regardless of the outcome of the claim. A high level of customer service and satisfaction will result in a high level of confidence with the adjuster.
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.
Mary was on her way to work one day. It was in the middle of winter, so there was ice on the road as well as the parking lot. While making her way to the office building, she slipped and fell down some steps, and broke her ankle.
#1 Cover the Basics
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 – with which states does the adjuster have experience?
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Extended Premises Doctrine – depending on the state, does this apply?
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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 ongoing construction in the parking lot?
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Is there an opportunity for subrogation?
These are some of the basic areas an adjuster should focus on to determine the compensability of any claim.
#2 Take Immediate Action
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.
#3 Review Video Footage
Video surveillance is common place these days for heightened security and has increasingly become part of the claim file. Whenever available, reviewing video footage should be on the adjuster’s checklist.
#4 Review the Claimant’s Medical History
Did the employee recently visit their primary care physician or walk-in clinic prior to the FROI and if so, are those records being reviewed? As discussed in a prior article, there are best practices when taking recorded statements that the adjuster should follow.
For example, there was a case where an employee claimed they twisted their ankle in the company parking lot upon arrival at work Monday morning and submitted a workers’ compensation claim. When reviewing various medical records from the physician and hospital, the adjuster discovered the employee sustained an injury over the weekend at a soccer game, and the claim was subsequently denied.
#5 Pay Attention to Details
Weather conditions during the day and time of the accident are essential. How is the adjuster verifying the weather conditions?
Simple Google searches will provide a lot of information. Sites such as www.wunderground.com can provide even more weather data. In addition to temperature, humidity, visibility, and wind for a given day, the site provides events such as fog and thunderstorms for each day down to the hour. In Mary’s example above, the adjuster was able to determine when the inclement weather started and determine if it was occurring at the time of her slip and fall. Did the freezing rain start at 7:00 am that Monday morning or was it 9:15 am?
Were parking lot 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 the claim handling, regardless if the claim was approved or denied, is what insurers expect from their adjusters. During the claim handling process, it is important to look at all the factors surrounding the accident to make the right decisions.
