1 / 23

NJ RIMS Chapter

NJ RIMS Chapter. Risk Management Day November 10 th 2009 Sentry Insurance Pamela Pezewski Senior Claims Specialist. THE BASICS OF WORKERS’ COMPENSATION & AGGRESSIVE CLAIM MANAGEMENT. COMPENSABILITY. WHAT ARE THE REQUIREMENTS OF COMPENSABILITY? Was there an accident?

beau
Télécharger la présentation

NJ RIMS Chapter

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. NJ RIMS Chapter Risk Management Day November 10th 2009 Sentry Insurance Pamela Pezewski Senior Claims Specialist

  2. THE BASICS OF WORKERS’ COMPENSATION & AGGRESSIVE CLAIM MANAGEMENT

  3. COMPENSABILITY WHAT ARE THE REQUIREMENTS OF COMPENSABILITY? • Was there an accident? • Was there notice? • Was there an injury? • Did the incident occur in the course of employment? • Did it arise out of employment? • Is there causal Relationship established?

  4. WAS THERE AN ACCIDENT WITH INJURIES? • ACCIDENT- an unexpected event that results in injury. • INJURY – Any change in the body that produces harm, pain, or decreased capacity for the body to function. An injury need not involve physical trauma but may include mental trauma. Injury may or may not be of traumatic nature; and could occur over time which we refer to as an occupational exposure.

  5. COURSE AND SCOPE • Injury must occur during the employment period. • It must occur where the employee is reasonably expected to perform their work activities. • The employee must be fulfilling their duties, or engaged in an activity related to their duties, or performing an activity for the betterment of their employer.

  6. ARISE OUT OF EMPLOYMENT • A compensable injury must be caused by an activity related to the employee’s job duties. An activity is related to the employment if it carries out the employer’s purpose or advances the employer’s interests either directly or indirectly. • The person’s work need NOT be the primary cause of the accident. If the employment and personal risks merge together to produce an injury, that injury will generally be held to have arisen from employment.

  7. CAUSAL RELATIONSHIP • If there was an accident, are the injuries claimed resultant of the accident? • Diagnosis? • Is it medically possible/probable for the work environment to have caused the medical problem? • Is it medically possible/probable that the medical problem is a result of personal life? • Did this condition pre-exist the work incident/injury? • Did we aggravate this pre-existing condition? Temporarily and/or permanently?

  8. Time to play:Is it workers’ comp? • I was cutting a bagel at my desk and cut my finger… • The machine jammed and it made me mad and I punched the wall… • I forgot to take my insulin and fainted and hit my head on my desk… • Instead of going down the stairs I jumped off the loading dock… • I had a car accident on the way into work… • I was running an errand and my boss asked me to pick him up a the newspaper and I slipped and fell… • I was lifting weights in our company gym during my break and hurt my shoulder

  9. Benefits of timely reporting? • Lock in accident facts • Lock in body part • Preserve evidence • Descriptions of accidents are like fish stories…the more time passes the bigger the fish…

  10. INVESTIGATION • Gather all pertinent facts – who, what, when, where, and how. • Determine injury/diagnosis as it relates to accident to determine causal relationship. • Profile the medical history. Priors? Pre- existing medical conditions? • Is there opportunity for subrogation? Second injury fund? Apportionment?

  11. Common Frustrations • We pay for carelessness! • Aggravation of a pre-existing condition is covered • Workers’ compensation laws are written to the benefit of the employee • A problem employee will probably be a problem claimant.

  12. BENEFITS WAGE LOSS • TTD (Temporary Total Disability) • TPD (Temporary Partial Disability) • PPD (Permanent Partial Disability) • PTD (Permanent Total Disability) • MEDICAL • VOCATIONAL RETRAINING

  13. MEDICAL/DISABILITY MANAGEMENT • KEYS TO SUCCESSFUL MEDICAL/DISABILITY MANAGEMENT -Prompt reporting to Carrier -Employer to assist with medical care -Ongoing communication -Early identification of problems -Aggressive use of transitional work -Proper utilization of vendors -Keep supervisors informed

  14. MEDICAL/DISABILITY MANAGEMENT EMPLOYER DUTIES: • Promptly report the injury • Timely onsite investigation • Ensure medical assistance • Communicate with the injured worker • Offer transitional work • Secure weekly status updates

  15. MEDICAL/DISABILITY MANAGEMENT CARRIER ROLE: • Indemnify injured worker • Ongoing proactive case management • Keep all parties informed • Biweekly contact with injured worker • Strategize for early return to work • Assure forward direction of case in support of early resolution • Identify need for additional services

  16. MEDICAL DISABILITY MANAGEMENTProper use of vendors • Is a nurse case manager assignment appropriate? • Any initial red flag (i.e. frequent change of physician, heavy prescription use, missed appointments, early attorney involvement) • Transitional duty return to work failure • Non cooperative medical provider (i.e. family doctor?) • Injured worker evasive, question extent of injury

  17. MEDICAL DISABILITY MANAGEMENTAdditional claim management techniques • Subrogation recovery • Surveillance – Approved vendors • Carrier In house Special Investigative Units with established relationships with local government and NICB • Offsets – Second injury fund/apportionment • Litigation

  18. CLOSING CLAIM FILES Key Elements to Effective Claim Resolution • Disposition plans that provide a clear and aggressive strategy, identifying pertinent issues and barriers to file closure, plans to resolve those issues and target date for claim resolution. • Disposition plans are followed and updated continually as information that affects the claim strategy is obtained

  19. The Ten Commandments of Workers’ Compensationthou shalt…. VI. Know Your Docs VII. Communicate VIII. Ask And Make Sure You Receive IX. Maintain a RTW Program X. Play By The Rules I. Report Claims Promptly II. Investigate Every Claim III. Keep Your Objectivity IV. Maintain A Relationship With Your Employees V. Know Your Adjuster(s)

  20. Questions?

  21. ..brought to you by: SENTRY INSURANCE A MUTUAL COMPANY; A+ RATED www.sentry.com STRENGTH-PROTECTION-VIGILANCE ESTABLISHED 1904

More Related