How to Tame Work Comp Claims – Interview with Lisa Scott

Published on Tue, 02/04/2014 - 15:50

Question: What do you do when an injured employee can’t return to work at YOUR business because she can barely walk … but she has no trouble walking all over town while running HER OWN karaoke business?

Answer: Get Heffernan Claims Consultants involved sooner than later!

This is exactly the scenario recently encountered by one of our clients. Although the knee injury claim was accepted, the nature and extent of the injury came into question – for good reason.  When the injured worker checked in at the client’s place of business, she moved very slowly, using a cane to walk. Meanwhile, she was seen performing karaoke all over town – no cane in sight! And, to add insult to injury, she had a public Facebook page with pictures of her performances. The client provided all of this information to the carrier, but the carrier never acted upon it. 

In this instance, we immediately scheduled a formal claims review with the carrier. We asked them to refer the case to their Special Investigative Unit (SIU) Division. We also asked them to object to the medical treatment and engage the Qualified Medical Evaluation (QME) process. The claim is now in the hands of the appropriate District Attorney’s office for potential prosecution because she was not only performing with no physical issues but she was also being paid for her karaoke services while collecting disability benefits which is illegal. Also, the carrier has ended temporary disability benefits to the employee based upon the current merits of the claim. Without Heffernan’s intervention, this progress would not be likely.   

Want to know more about how Heffernan’s Claims Consulting team can help you tame workers’ compensation claims? Read the interview below with Lisa Scott, our Claims Consulting Manager.

Q: Tell us about your team and who you serve.

Lisa: We serve workers’ compensation clients across the nation from our offices in California, New York, Missouri and Portland.

Q: Do you provide experience modification reviews? How are they beneficial for employers?

Lisa: The Experience Modification is truly the only thing that an employer has control over that directly affects insurance premium. If employers are proactive with their claims management, their claim costs are likely to be less – which means their Experience Modification will have a positive effect on their insurance premiums. 

Q: Do you recommend that clients wait until there’s a problem or should they engage your services before there is an issue?

Lisa: We encourage clients to engage our services immediately! We have found that it is always best to be on the offensive side of risk management.

Q: What is the biggest mistake that companies make when a claim is filed?

Lisa: Actually, there are two mistakes in my opinion. 

The first is not treating injured workers with respect once they file an industrial injury. The workers’ compensation system is definitely challenging and expensive – so we understand how frustrating it can be when a claim occurs. However, a little kindness goes a long way with those who are legitimately injured – and can make the difference between workers litigating their claims vs. returning to work as quickly as possible. 

The second mistake that I see is employers not having a formal Modified Duty Program and, thus, failing to get injured workers back to work, on modified duty, as quickly as possible. Statistically, the life of a claim just about doubles if you allow an injured worker to stay home and get comfortable. Keep them engaged in your workforce.     

Q: What are the first three things companies should do when they receive notice of a claim?

  1. Offer the injured worker a Claim Form. If the worker turns it down, document the fact that it was offered.  By doing this, the employer preserves its ability to investigate the claim at a later date. 
  2. Investigate the injury immediately after it occurs or is reported to you. No matter how small the injury may seem, secure in writing how the injury occurred from the injured worker, collect witness information and statements and take pictures of the injury site. You would be surprised at how this information can change over time. Preserve the evidence. 
  3. Report the injury immediately to your workers’ compensation carrier - do not wait! And, if you are not sure if it is industrial or not, or it is found to be questionable in any way, immediately contact your broker/broker consultant and ask for assistance with reporting of the claim to the carrier. Your broker/broker consultant can help ensure the carrier handles the claim appropriately and investigates fully before just accepting the injury outright.    

Q: What else do Heffernan clients need to know?

Lisa: The Claims Consulting Team has one goal – and that is to be sure our clients have the best experience possible with their workers’ compensation program. We encourage our clients to ask us any questions they have and engage us early in any issues they may have. Please know that our advice is not only based upon years of practical experience, but also based upon the fact that we want our clients to thrive in a very challenging system. 

Want to learn more? Contact Lisa directly at (925) 295-2560.