When an employee makes a claim for workers’ compensation benefits, it’s imperative that the claim be reported timely. An adjuster’s job is to work quickly and efficiently to gather facts surrounding the accident. The adjuster will often take a recorded statement to memorialize the accident details, as stories and facts may change over the course of a claim. A timely investigation can reveal details that can have a big impact on a claim’s outcome, including identification of a possible third party.
A good investigation requires a collaborative effort between you and the adjuster. You can play a pivotal role in helping identify important information during the claim investigation process. You may be privy to important information that could change the outcome of the investigation; for example, a coworker who comes forward and indicates the injured worker previously mentioned that an injury took place at home, not work.
Ways to help with a claim investigation:
- Require supervisor reports that capture initial details about what’s being claimed. This helps memorialize information from the onset. Stories can sometimes change with time or as information is relayed from one party to another.
- Help the adjuster obtain any written/verbal witness statements.
- Help coordinate communication between the adjuster and injured worker. For example, if an adjuster is having trouble reaching an injured worker, you can coordinate a time at work to help both parties connect. This can also extend to supervisors and coworkers with whom the adjuster may need to speak to about the claim.
- Inform the adjuster of any red flags, concerns, or issues. Something that may seem insignificant can influence how the claim is evaluated.
You can also play a vital role in helping the adjuster in the investigation and evaluation of subrogation. A successful recovery against a third party can lead to reduced claim costs.
Ways to help identify third-party involvement:
- Scene preservation. If there’s a suspected product defect or machine malfunction, it’s important to work with the adjuster to determine if the machine must be removed from production to allow for further investigation. This could also apply to a malfunctioning piece of equipment, such as a ladder.
- Obtaining pictures. With technology and camera phones, it’s easier than ever to obtain pictures that may be important in the evaluation of subrogation. Pictures can help preserve the scene, and ultimately be the difference in a successful recovery from a third party.
- Sharing police reports, contracts, and other documents with the adjuster can also be important in the evaluation of subrogation. Contractual agreements may need to be reviewed to determine if there was a duty owed/breached.
Great claim outcomes begin with prompt and strong investigations. A collaborative effort is necessary for the claim investigation to be thorough.
A thorough investigation helps assure the compensability decision is appropriate and any potential subrogation opportunity is preserved.
This blog was written by Ben Lanser, work comp claims manager
