Claims adjusting is getting more complicated. Although workplace fatalities are becoming rarer, cumulative or repeated injuries are becoming more common. These types of claims take expertise to adjust.
As an example, consider a 55-year-old auto mechanic who has had knee problems for 20 years. He's had several surgeries on his right knee, but none of them cured his problem. Over the years, he over-compensated for his bad knee, causing injury to his good knee. He may need more surgery, or he may need a disability settlement, including an open medical treatment plan. Those factors alone require the skills of an experienced claims adjuster.
Now, consider that the man worked for several different employers over the last 20 years, each with a different workers' comp carrier. The current adjuster needs to work back through the files to identify each carrier and then begin an involved process that leads to apportionment of the claim, however it is settled.
For the auto mechanic, one of the key factors in this claim is his age. According to the Bureau of Labor Statistics, employees over 55 years old are significantly less likely to be injured than employees 20 to 24 years old. However, once injured, older workers are more likely to have poor surgical outcomes and need more time to recover. A good claims adjuster recognizes the complications surrounding age and factors them into the overall plan.
A complex claim needs a top-notch adjuster with a broad set of skills:
PLANNING: An adjuster needs to develop an action plan that includes investigation and research, return-to-work options, monitoring of medical and pharmacy utilization and settlement options. The investigation should explore the possibility of pre-existing conditions and verify the injury occurred in the workplace.
UTILIZATION: With medical costs skyrocketing, it is crucial for an adjuster to be part of the team that analyses utilization of medical treatments and drugs. The adjuster needs to understand the interlocking relationship among treatments, drugs and early-return-to-work to find the best balance of effectiveness and cost, while addressing the employee's desire to get well.
APPORTIONMENT: A good adjuster recognizes opportunities for recovery of claims paid and for apportionment of current claims filed with other workers' comp carriers.
COMMUNICATIONS: An adjuster needs to maintain excellent communications among the injured worker, the employer and the treating physician. An adjuster should have only a reasonable number of files to handle so that he or she can return phone calls and emails promptly and encourage everyone to work proactively on the treatment plan.
LOSS CONTROL: A skilled adjuster can help employers recognize claim trends and recommend loss control measures.
What Employers Need to Ask
Continuity is extremely important. When an adjuster moves to another company or assignment mid-claim, your claim could fall through the cracks, resulting in delayed treatment, a disgruntled employee and increased costs. When an adjuster is assigned to one of your cases, it is appropriate to ask about the adjuster's:
· Length of time with the company
· Number of years as a workers' comp adjuster
· Number of new claims assigned to him/her each month
· Number of open claims files
· Types of claims
· Use of electronic versus paper files.
For more information, please contact the PCOC Insurance Program department at Jenkins Insurance Services at (877) 860-7378.