Develop a Claim Reporting Process
Every employer should have a specific, written procedure for employee injury/incident reporting. Every employee should know to whom they report accidents. Your procedure should be posted and included in your employee handbook. Supervisors should know (and follow) the procedure.
What Incidents Are to be Reported?
Many employers track incidents and report only injuries to their workers’ compensation insurer. An incident is an unusual event that either results in an injury or could have resulted in an injury. A person stumbling off a ladder is an incident. Tracking such can show problem areas in the operation. Why did the person stumble? Is the ladder unsafe or was it set up improperly?
Obviously only accidents resulting in injury are reported to your workers’ compensation insurer. However, tracking incidents may prevent future injuries.
In most states you must report incidents where there is medical attention provided or lost time from work. Check with your insurer on your state’s requirement.
Report claims quickly to your insurance carrier.
Put them to work fast.
Be Aggressive With Insurance Fraud
In most states insurance fraud is a crime. Here are some indicators that may point to a fraudulent workers’ compensation claim.
*The alleged injury occurred on a Monday morning or late Friday afternoon but was not reported until the following Monday.
*The accident occurred just prior to a layoff, strike or seasonal shutdown.
*There are no witnesses to the accident.
*There is a history of the claimant reporting previous questionable claims.
*There is a delay in reporting the accident.
*The claimant has recently purchased a disability policy.
*The accident is alleged to have happened outside of normal working hours.
The presence of two or more of the above may indicate fraud. Report your suspicions to your insurance carrier. Do not comment on your suspicions to the employee.
Pick a Physician to Treat Your Employees
Designate your health care professionals in advance. Many states allow the employer to select the injured worker’s health care provider for the first ten days after an injury. This provides control over the loss, right from the beginning. Develop a relationship with your provider. Let them get to know you. Most hospitals now have an occupational health center that is well versed in workplace injuries, therapies, and the workers’ compensation payment system.
Review Your Loss Runs Regularly
Your insurer can provide you with a listing of losses paid under your policy. Look for claims that are not yours. Also, review the amounts shown on the report. Any claim that is not yet closed will show “reserves” (what the insurance company expects to pay out). Do the reserves make sense? A one year old claim with payments of $1,500 and a reserve of $75,000 may warrant a second look. Work with the adjuster for explanations or to make any needed changes.
Have Your Insurer Assign One Adjuster to All Your Claims
If you typically have several workers’ compensation incidents a year, it is best to have one adjuster for all claims. Establish a relationship with the adjuster and let him become familiar with your operation. Some insurers will assign one adjuster or team to your medical-only claims and a separate adjuster on claims involving lost time.
Push Insurers to Subrogate Claims
Workers’ compensation is considered a sole remedy for workplace injuries. Employees may not (in most states and in most circumstances) sue their employers for their injuries. However, when a third party is responsible for the injuries, employees may seek a legal remedy from the third party. The workers’ compensation insurance company may also seek reimbursement; called subrogation. For example, an employee is driving to a sales call and is rear-ended by an inattentive driver. Workers’ compensation pays for the employee’s injuries. The workers’ compensation insurer should then go to the other driver’s insurance company for reimbursement of payments made.
Subrogation reduces the net losses paid by your insurance company. It also reduces amounts that show up on your experience modification calculation. Push your adjuster to subrogate any claim where other parties may be responsible for the accident.
Talk to Your Adjuster Quarterly About Open Claims
Plan to review your claims at least quarterly with your adjuster(s). Phone reviews work well. Three questions to ask for each claim:
*What have you done on this claim?
*What are you doing now?
*What are you going to do in the future?
Get Involved in Claims
The leaders of your company must be involved actively in workers’ compensation claims. Everyone in your operation must know that you take workers’ compensation and employee safety seriously.
Aggressive Claims Management Gets Employees Back To Work Quickly.
Use Return to Work Plans
It is almost always best to get an injured worker back to work quickly. Sometimes, light duty or a reduced work schedule are called for. Work with the adjuster and the treating physician to develop a plan that works for you and the employee. Prepare job descriptions that include the physical requirements of the employee’s job or proposed job. The treating physician can use these to approve light duty programs.
Stay in Touch With Injured Workers
If you have an employee out for an extended period of time, keep in touch. Don’t let injured workers feel forgotten. Have someone send a regular email with information on office/shop news. Make sure your employee (they are still your employee) knows about the things that go on in any workplace – new accounts gained, employee promotions, new babies, and the like. Arrange for injured workers to come by for lunch with the people in their departments.
The psychology of an injured worker is too deep for this book. However, too often, good employees feel like they are letting the team down by being hurt. The guilt turns into withdrawal. The withdrawal turns into self-pity. Which can turn into resentment. It is, at this point that claims can turn adversarial.
Regular contact with injured workers’ will help keep their morale high. The objective should always be to get them back to work.
Notify Your Insurer if You Suspect Fraud
Unfortunately the system is not perfect. Employees may fake or inflate a claim. Malingering can occur. Fraud costs insurers and ultimately insurance buyers hundreds of millions of dollars. You are the front line of defense against fraud.
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