Compensability
A compensability decision should be made on a claim within this many days
Within 20 days of claim assignment
This is when you can update your POA and close a claim
Whenever treatment has concluded for the injured worker and all medical benefits are paid
This must be updated prior to updating reserves
POA
You should make employee and employer contacts to verify lost time or wages when
Always, every single time
A subrogation referral should be submitted within how many days
Within 3 days of completing the investigation or within 20 days
These are two of the four exclusions to AOE/COE
Unexplained falls, idiopathic illness, minor insubstantial movements, assault in the workplace for personal reasons
These are two vendor resources available to help you create a POA
CLARA analytics and ODG
An adjuster post changes to reserves within this many days
Within 10 business days of receipt of the new information that changes the probable exposure of the claim
The waiting period, in days, for lost time benefits to be considered by a Claim Specialist
7 days
You need this in order to submit a referral for a hospital and pharmacy trace
Medical authorization, zip code of the injured worker
Under the Coming and Going Rule, this is an example of when an injury would be covered
Injured on the employer’s premises
These are two things that can impact how quickly a claim is resolved
Injury type, job demands, medical history, motivation of the injured worker, cooperation of the employer, cooperation of the provider, availability of light duty
Reserves at any point in time must reflect the best estimate of the adjuster’s ________ ________ _______ to the company
Probable ultimate cost or ultimate probable cost (PUC or UPC)
You should transfer a claim to a Claim Specialist when
Within 24 hours of identifying past, present, or future lost time that may exceed the waiting period
3 questions to ask during a slip and fall injury investigation
Was the employee carrying anything? What were the lighting conditions? If indoors, what was the flooring surface and condition? If outdoors, was there ice/snow/an active storm? Who was responsible for salting/sanding/plowing?
An employee entitled to workers compensation benefits when
An injured worker that receives a personal injury that arises out of and in the course of employment is entitled to workers compensation benefits
Two reasons a plan of action is important on every claim
Shorter claim duration, lower total claim cost, creates adjuster-driven claim files, creates accountability for the adjuster, serves as documentation on the claim, allows for transparency between MEMIC Claims, MEMIC Underwriting, and the Insured
A reserve notification diary be automatically sent to an adjuster when
When reserves are low and when reserves reach $50,000
The 3 types of non-consecutive lost time are
Reduced hours, reduced wages, losing full non-consecutive days
You should do this when you receive an ISO Report, and you would receive an ISO Diary when
Any time you receive an ISO Report, document the report in the file in its own notepad. Look for any similar injuries or red flags and document them. An ISO diary will be sent automatically if the ISO Report yields a score of 650 or higher
Prior to determining compensability on a mental stress claim, you should do this as part of your investigation
Mental Stress Employee Contact Template and recorded Employee statement, Mental Injury Medical Authorization should be returned, all prior records should be requested and received, Hospital and pharmacy trace should be considered, background check should be considered, and speak with your CTM prior to agreeing to pay for the claim
A way that an adjuster can take action to manage the medical portion of a claim
Proactively pursue medical records, approving or denying medical referral requests, utilizing diaries to trigger claim actions
This is one internal impact and one external impact of reserving
Internal: Leadership understanding of files, accurately price policies, investment strategies. External: Yearly policyholder returns, agent profitability, financial strength rating
3 places where you can find information about lost time (other than talking to the employee and employer)
FROI, statement of the injured worker, medical records, provider contact, prior notepads, legal findings
3 common red flags on a claim
Employee only returning calls during non-business hours; injury occurs prior to a layoff, termination, strike, or business closure; injury follows a disciplinary action/demotion; spotty job history; poor attendance/performance; history of prior claims; claimant repeatedly misses medical appointments; objective testing does not match subjective complaints