WC Claim Disputes
How often do you dispute a WC claim? My boss questions almost every single one. I don't really agree with their methods. Curious if this is common practice or is my boss one of a kind? In certain situations, yes, I can see myself questioning a claim but most of ours are very reasonable and make sense based on the work performed. It's disappointing when more time is spent disputing a claim rather than figuring out how to make sure it doesn't happen again.
Comments (26)
By the way Grant, when you handle the claim do you represent the company at court? Self Insuring claims allows you to properly manage each claim on its merits. Much better than even having a third partly handle claims.
Workers Compensation is an element of work that is an area that has the potential for fraud. In the same vain it is a circumstance for those workers, not paying attention, poorly / improperly trained, trying to place responsibility onto the employer for a non work related injury and in some cases a chance to retire with an income. Point there is no one glaring reason to deny any claim providing you have done a thorough investigation and found that the injury lines up with the statements of all involved.
There is one element that can cause even the most open minded department to question the claim; the workers compensation board themselves. New York State is one such board that finds everything on behalf of the injured no matter the circumstance. Another mentioned element, don't fully trust or depend on your insuring company to properly handle every claim. They don't want to spend their time, in many cases, questioning any part of the claim sometimes. A more common issue seen by the insuring company is poor medical management.
Good case management will ensure prompt, quality treatment of every claim despite any dispute. Insuring a good investigation that is based on fact finding with absolutely no bias. Finally, any claim where there are no witnesses and / or there is no timely reporting immediately is suspect. Please don't assume guilt, just suspicion where facts will prove or disprove.
Once litigated, use the information to improve the workplace.
Employers do not dispute the claim - the WC adjuster does. We can question claims all we want, but the adjuster makes the final determination if it gets paid or not. Our job is to provide the facts of the case and get the employee back to work as soon as we can.
In my opinion, there should be a separation with WC and safety that they only work together to investigate and on RTW, just like production is kept separate from safety. Even though they need to work together, the same person shouldn't handle both.
I would only let my WC carrier or adjust know that I question the injury if the scope of work, job duties, and injury do not add up. Even so, my opinion means nothing if the facts are not there to back it up.
Except in rare cases, we typically do not dispute a WC claim, although the carrier may based on the situation.
My priority is to provide proper medical treatment and root cause analysis to determine what needs corrected to ensure it doesn't happen again!
We don't dispute any claim. We see it as a decision the insurance agency will make. We want to make a good faith effort to cover the employee and also not back ourselves into a corner for disputes. We draw up paperwork for every accident regardless of severity. If a an injured employee has any issues later that require medical fees we are ready and if there is a valid reason the claim isn't covered (coming and going rule, deliberate act, etc) then our insurance and their legal team will make the call.
In my opinion, disputing every claim shows your employees that the safety department has a major distrust in them, which is never good. As long as you have a timely incident reporting program and conduct a solid incident investigation after an employee is hurt or injured you'll know whether or not a claim should be disputed.
I definitely understand your disappointment. I handle WC for a self insured employer. Feel free to message me if you feel I could be some assistance!
I only have brief experience with WC but it seems to be a trend to dispute most claims to keep costs down. Unfortunately WC is a major expense for companies so sometimes if there is little evidence or reporting to suggest there was a problem (especially for terminated employees) it makes sense to dispute it or offer a lesser settlement. I have never seen anyone dispute claims that were reasonable with documentation, especially not recent injuries.
That’s unfortunate. It may be more worthwhile to channel the time and energy into programs aimed at addressing the root causes of the injury. MSDs could be addressed through a robust ergonomics program. Slips, trips, and falls could be addressed by a full site walkthrough and housekeeping review. Equipment-related injuries could be addressed in partnership with your facilities/maintenance and operations stakeholders.
Mind giving an example of the claim? Doesn’t have to be specific, but high level light help. Wondering if bonuses are based on claims savings. My opinion, pay the people unless it blatant fraud
We rarely dispute a claim. If everything was reported promptly, was within their scope of work and the post accident drug and alcohol test was negative I don't see a reason to dispute the claim. In my old age I've become more cynical and I do look for certain outliers or indicators that a claim may be fraudulent. These are no witnesses, working alone, not working where they should be, changing story etc.
When people care more about optics than actually keeping people safe - they tend to dispute everything. Someone like that would dispute every worker's comp claim rather than take any form of responsibility for things.