One of the things our team prides themselves on is identifying potential issues early on in workers’ compensation claims. Some of these can be so obvious that the employer will clue us in during the initial contact, but some are a bit more nuanced – and that’s where our expert claims examiners come in. Most people handling workers’ comp for a business know that a Friday afternoon or Monday morning injury is a little suspicious, even more if there were no witnesses. However, there are other scenarios that employers may not consider relative to the validity of a claim, and it’s our job to gather that information and educate our clients on how to handle it. Here are a few examples of details that sound our alarms, both early on in the claim, and as it progresses.
- Claimant is hostile about answering any questions regarding the accident, or provides very vague answers.
- Immediate representation by an attorney.
- The details (like date, time and place of accident) are unknown or can’t be recalled.
- Late reporting of the injury. Not everyone seeks medical treatment right away, but an incident report (with witness statements) should be completed even if first aid isn’t needed. The statute of limitations in Ohio is 12 months from DOI. If witness statements don’t corroborate the claimant’s story or are all different, that could be another red flag.
- Claimant can’t be reached – never answers the phone, or always seems to be busy.
- Claimant engages in secondary or self-employment, has other non-work-related injuries, or participates in athletic activities outside of work.
- Claimant wasn’t in good standing at the time of the incident – poor attendance record, poor performance or frequent disciplinary problems;
- Claimant quits just before or just after the injury; injury coincides with layoffs, end of seasonal work, plant closure, or approaching retirement.
- Claimant changes physicians immediately following emergent care, or as soon as the treating provider releases them to full duty.
- Claimant’s wages were recently subject to garnishment or liens.
- The physical injury doesn’t match the incident or isn’t consistent with nature of the claimant’s work.
This list isn’t all encompassing, but it’s enough to provide an idea of the myriad of details we consider when managing a claim. If your business has had a workers’ comp claim where one or more of these situations have presented themselves, did you feel like your concerns were taken seriously by the TPA paid to support you on claims management? If the answer isn’t yes, we’d like to learn more about the kind of support your organization needs, and how SuretyHR can deliver it. Contact us by phone at (440) 249-5260 or complete this quick form.
