Post on 12-Jan-2016
Why Are My Workers Compensation Costs So
High?
Claim Handling Strategies
Leads Arthur J. Gallagher Risk Management Services, Inc.’s claims practice in the Midwest region and provides senior level expertise in claim negotiation and resolution to client claim problems. She has 30 years insurance claims experience and is quoted in several industry publications regarding holding down claim costs. Past Vice president-Board of Directors-West Suburban CPCU Chapter, holds CPCU and CPD designations.
Barbara Galluppi, CPCU
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Goal of Workers’ Compensation
To return the injured worker as close to their pre-injury status as possible Mentally Physically Emotionally
while protecting the interests of the insured/employer.
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Control Your Claims Destiny
Knowledge is powerThe worse the economy is the more fraud
perpetratedAdjusters have around 175 cases sometimes
more Investigations are the most critical and most
overlooked aspect of a claim and the most costly when poorly done.
Compensability Criteria
Existing employer/employee relationshipFortuitous injury or occupational diseaseArise out of the scope of employment (AOE)Occurred in the course of employment (COE)Causal relationship between employment and
the injury or disease
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Workers’ Compensation Defenses
No employer/employee relationshipNot in course and scope of employmentNo causal relationshipAssault and battery Intentionally self-inflicted injuriesSuicideStatute of limitations
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Member Participation in the Trial/Arbitration Process
Attend all trials possibleLine up employee witnessesCommunicate with counsel
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Employer/Employee Relations Can Obviate Litigation
Maintain contact and communication with injured workers
Assure them they are getting what they are entitled to
Remind them that an attorney would get a good portion of benefits
Advise to wait and see what the insurance company does for them
Work to alleviate their concerns
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“… but doctor, I lift elephants all day …”
Job Analysis
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Internal Claims Management
Have a bank of job descriptions ready to go for normal duties as well as possible transitional duty positions.
Develop relationships with clinics and physicians.Utilize all resources
Claim Administrator Risk Control Broker Work on reserve reductions where applicable.
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Internal Claims Management
First Report of Injury (Original to claim department.) This is the first
report of injury required by the state.Supervisor’s Report
This is your internal report, completed by the claimant’s immediate supervisor.
Notify Loss Control (If applicable.) Immediately correct hazard.
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Internal Claims Management
Witness Statements (If available.) Immediately talk to the injured
worker’s coworkers regarding what they saw, heard, or did not observe.
Results of Internal Site InvestigationMaintain a report of the internal findings, post
accident.Names of CoworkersPrepare a list of the employees that were in the
vicinity of the claimant on the date of incident.
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Internal InvestigationWage Statement
On lost time cases provide the insurance carrier with the injured worker’s weekly wages for the past 12 months.
List overtime wages separately. If overtime is over 50% of claimant’s straight
time, it is included in the AWW.Application for Employment
This should be kept handy for possible forwarding to the claim handler in the event of misrepresentation by the employee.
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Internal Investigation
Daily Log of Activity Phone calls, conversation with claimant, claim
administrator, physician, etc. Chronological reporting of activities regarding
claim and injured employee may be necessary and especially important should you be called to testify at a hearing
–Also aids compensability investigationCopies of All CorrespondenceSigned Medical Authorization
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Excellence vs. Mediocrity
Poor investigations are the leading
cause of lost dollars
Expectations
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Expectations
Three-point contactWitness statementsEmployee statementsEmployee interests, hobbies, family physicians,
medical historyJob descriptionsModified/transitional dutyPrompt payments
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Expectations
Verification of lost time IME’sSurveillance/activity checkMedical/vocational rehabilitationMedical cost containmentSubrogationPrior medical records
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Biggest Fraud PotentialCumulative Trauma
Priors-Trace companiesMedical history-detailedSports, hobbies, special interestsOther employees as resourceJob description/snapshot (Bank them)Normal and Transitional dutyEXACT medical restrictions
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Cumulative Trauma Claims
Obtain the EXACT medical restrictions keeping the claimant off work
Obtain the EXACT offending job duties and tasks being alleged as harmful
Medical history, including the name of the family physician
Prior medical records including Trace America search, if necessary
Sports, hobbies and special interests and other spare time activities of the claimant
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Cumulative Trauma Claims
Job description for regular and transitional dutyPrior employment history and records if possibleComparison of prior medical records with current
records to establish if the condition has changed, is truly an aggravation and to determine when any such alleged aggravation has long since resolved bringing the claimant back to the pre-injury status.
Ask the doctor to comment on causal relationship after all the information is in on prior medical and the job description is available.
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Questions & Answers
Ms. Barbara Galluppi, CPCU
Arthur J. Gallagher Risk Management Services, Inc.Two Pierce PlaceItasca, Illinois 60143630-694-5490
Barbara_Galluppi@AJG.com