ER/EE
An Employee should report a possible workers compensation injury to this person
A supervisor or other person of authority
These are the indicators that an Employee may not be covered by the policy
Employee has the same last name as the Employer, Employee is listed as a volunteer, Employee is an independent contractor, etc.
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, etc.
You should you make employee and employer contacts to verify lost time or wages when
Always, every single time
Two reasons to close a claim are
Inactivity lasting two months, injured worker refuses care/benefits, 30 days after a denial without appeal, full duty return to work with all bills paid
The definition of an Employer, per the WCB, is this
An entity that provides direction and control over another for payment of a wage
You know when your initial investigation is complete when
When you have made all required contacts and have determined whether or not the claim fits AOE/COE
An adjuster should post changes to reserves within how many days
Within 10 business days of receipt of the new information that changes the probable exposure of the claim
These are the 3 types of non-consecutive lost time
Reduced hours, reduced wages, losing full non-consecutive days
You should document this in a notepad prior to transferring a claim to Indemnity
Brief summary of the claim facts including: EE demographics, summary of the injury, treatment, work capacity; lost time to date/future lost time; reason for transfer; diary to assigning assistant
If an Employee is not losing time from the Insured but is losing time from their concurrent employment, you should do this
Track lost time/wages to see if it should be transferred to a Claim Specialist
When would a pre-existing condition be compensable
If the Employee can prove a significant aggravation to a pre-existing condition, the claim may be compensable
This is 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
True or False: If the medical portion of a claim is compensable, the lost time will also be compensable
False
The two types of offsets are these and they are defined as
Subrogation – the right to pursue a 3rd party that caused an insurance loss to the Insured
Apportionment – the act of dividing and allocating costs between insurers
True or False: Incarcerated persons are not entitled to workers compensation benefits
False – these claims should be investigated and may be compensable
These are the steps you should take if you have a claim for a right knee injury and you receive a bill for a left shoulder appointment
Contact the Employee to see if the Employee thinks it is related to the right knee. If the Employee thinks it is related, investigate further and make your compensability decision. If the Employee states it is not related and just a mistake, let the Employee know you will deny the bill and send the provider, Employer, and Employee a copy of the paperwork. Notify the Employer of the reason for the denial. File the denial and set a diary to check back for any appeals. Consider updating reserves if it seems like the Employee would appeal
Two reasons a plan of action is important on every claim are
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
These are 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
Two reasons to reopen a claim are
Injured worker revisits medical care for the injury, injured worker pursues legal action, notice is received from the State body (WCB) requiring action
The waiting period for lost time benefits for a firefighter is
There is no waiting period – if there is a firefighter with lost time, transfer to a Claim Specialist
3 reasons for additional investigation are
Facts of the file change, surgery is being discussed, restrictions increase, treatment continues beyond what you would expect
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.
This is how to track for an Employee losing time or wages
Day 8 spreadsheet – collect gross wages from the Employer to come up with an estimated AWW. Obtain gross wages weekly from the Employer and determine the amount of wages lost. When that total nears day 5, transfer to a Claim Specialist
One treatment MEMIC would not approve is
PRP injections, IDD (traction therapy), cold laser therapy, anything considered experimental or not FDA-approved