NJ RIMS ChapterNJ RIMS Chapter

Risk Management Day Risk Management Day

November 10November 10thth 2009 2009

Sentry InsuranceSentry Insurance

Pamela Pezewski Pamela Pezewski

Senior Claims SpecialistSenior Claims Specialist

THE BASICS OF THE BASICS OF WORKERS’ WORKERS’

COMPENSATION & COMPENSATION & AGGRESSIVE CLAIM AGGRESSIVE CLAIM

MANAGEMENTMANAGEMENT

COMPENSABILITYCOMPENSABILITY

WHAT ARE THE REQUIREMENTS OF WHAT ARE THE REQUIREMENTS OF COMPENSABILITY?COMPENSABILITY?

Was there an accident?Was there an accident? Was there notice? Was there notice? Was there an injury?Was there an injury? Did the incident occur in the course of Did the incident occur in the course of

employment?employment? Did it arise out of employment?Did it arise out of employment? Is there causal Relationship established? Is there causal Relationship established?

WAS THERE AN WAS THERE AN ACCIDENT WITH ACCIDENT WITH INJURIES?INJURIES? ACCIDENT- an unexpected event that ACCIDENT- an unexpected event that

results in injury.results in injury. INJURY – Any change in the body that INJURY – Any change in the body that

produces harm, pain, or decreased produces harm, pain, or decreased capacity for the body to function. An capacity for the body to function. An injury need not involve physical trauma injury need not involve physical trauma but may include mental trauma. Injury but may include mental trauma. Injury may or may not be of traumatic nature; may or may not be of traumatic nature; and could occur over time which we and could occur over time which we refer to as an occupational exposure. refer to as an occupational exposure.

COURSE AND SCOPECOURSE AND SCOPE

Injury must occur during the Injury must occur during the employment period.employment period.

It must occur where the employee is It must occur where the employee is reasonably expected to perform their reasonably expected to perform their work activities.work activities.

The employee must be fulfilling their The employee must be fulfilling their duties, or engaged in an activity related duties, or engaged in an activity related to their duties, or performing an activity to their duties, or performing an activity for the betterment of their employer.for the betterment of their employer.

ARISE OUT OF ARISE OUT OF EMPLOYMENTEMPLOYMENT A compensable injury must be caused by A compensable injury must be caused by

an activity related to the employee’s job an activity related to the employee’s job duties. An activity is related to the duties. An activity is related to the employment if it carries out the employment if it carries out the employer’s purpose or advances the employer’s purpose or advances the employer’s interests either directly or employer’s interests either directly or indirectly. indirectly.

The person’s work need NOT be the The person’s work need NOT be the primary cause of the accident. If the primary cause of the accident. If the employment and personal risks merge employment and personal risks merge together to produce an injury, that injury together to produce an injury, that injury will generally be held to have arisen from will generally be held to have arisen from employment.employment.

CAUSAL RELATIONSHIPCAUSAL RELATIONSHIP

If there was an accident, are the injuries If there was an accident, are the injuries claimed resultant of the accident?claimed resultant of the accident?

Diagnosis?Diagnosis? Is it medically possible/probable for the work Is it medically possible/probable for the work

environment to have caused the medical environment to have caused the medical problem?problem?

Is it medically possible/probable that the Is it medically possible/probable that the medical problem is a result of personal life?medical problem is a result of personal life?

Did this condition pre-exist the work Did this condition pre-exist the work incident/injury? incident/injury?

Did we aggravate this pre-existing condition? Did we aggravate this pre-existing condition? Temporarily and/or permanently?Temporarily and/or permanently?

Time to play:Time to play:Is it workers’ comp?Is it workers’ comp?

I was cutting a bagel at my desk and cut my finger…I was cutting a bagel at my desk and cut my finger… The machine jammed and it made me mad and I The machine jammed and it made me mad and I

punched the wall…punched the wall… I forgot to take my insulin and fainted and hit my head I forgot to take my insulin and fainted and hit my head

on my desk…on my desk… Instead of going down the stairs I jumped off the Instead of going down the stairs I jumped off the

loading dock…loading dock… I had a car accident on the way into work…I had a car accident on the way into work… I was running an errand and my boss asked me to pick I was running an errand and my boss asked me to pick

him up a the newspaper and I slipped and fell…him up a the newspaper and I slipped and fell… I was lifting weights in our company gym during my I was lifting weights in our company gym during my

break and hurt my shoulderbreak and hurt my shoulder

Benefits of timely Benefits of timely reporting?reporting? Lock in accident factsLock in accident facts Lock in body partLock in body part Preserve evidencePreserve evidence

Descriptions of accidents are like Descriptions of accidents are like fish stories…the more time fish stories…the more time passes the bigger the fish…passes the bigger the fish…

INVESTIGATIONINVESTIGATION

Gather all pertinent facts – who, what, Gather all pertinent facts – who, what, when, where, and how. when, where, and how.

Determine injury/diagnosis as it relates Determine injury/diagnosis as it relates to accident to determine causal to accident to determine causal relationship.relationship.

Profile the medical history. Priors? Pre- Profile the medical history. Priors? Pre- existing medical conditions?existing medical conditions?

Is there opportunity for subrogation? Is there opportunity for subrogation? Second injury fund? Apportionment?Second injury fund? Apportionment?

Common FrustrationsCommon Frustrations

We pay for carelessness!We pay for carelessness! Aggravation of a pre-existing Aggravation of a pre-existing

condition is coveredcondition is covered Workers’ compensation laws are Workers’ compensation laws are

written to the benefit of the written to the benefit of the employeeemployee

A problem employee will probably A problem employee will probably be a problem claimant.be a problem claimant.

BENEFITSBENEFITS

WAGE LOSSWAGE LOSS TTD (Temporary Total Disability)TTD (Temporary Total Disability) TPD (Temporary Partial Disability)TPD (Temporary Partial Disability) PPD (Permanent Partial Disability)PPD (Permanent Partial Disability) PTD (Permanent Total Disability)PTD (Permanent Total Disability) MEDICALMEDICAL VOCATIONAL RETRAININGVOCATIONAL RETRAINING

MEDICAL/DISABILITY MEDICAL/DISABILITY MANAGEMENTMANAGEMENT KEYS TO SUCCESSFUL KEYS TO SUCCESSFUL

MEDICAL/DISABILITY MANAGEMENTMEDICAL/DISABILITY MANAGEMENT--Prompt reporting to CarrierPrompt reporting to Carrier

-Employer to assist with medical -Employer to assist with medical carecare -Ongoing communication -Ongoing communication

-Early identification of -Early identification of problemsproblems -Aggressive use of -Aggressive use of transitional worktransitional work -Proper -Proper utilization of vendorsutilization of vendors-Keep supervisors informed-Keep supervisors informed

MEDICAL/DISABILITY MEDICAL/DISABILITY MANAGEMENTMANAGEMENT

EMPLOYER DUTIES:EMPLOYER DUTIES: Promptly report the injuryPromptly report the injury Timely onsite investigationTimely onsite investigation Ensure medical assistanceEnsure medical assistance Communicate with the injured Communicate with the injured

workerworker Offer transitional workOffer transitional work Secure weekly status updatesSecure weekly status updates

MEDICAL/DISABILITY MEDICAL/DISABILITY MANAGEMENT MANAGEMENT

CARRIER ROLE:CARRIER ROLE: Indemnify injured workerIndemnify injured worker Ongoing proactive case managementOngoing proactive case management Keep all parties informedKeep all parties informed Biweekly contact with injured workerBiweekly contact with injured worker

Strategize for early return to workStrategize for early return to work Assure forward direction of case in Assure forward direction of case in

support of early resolutionsupport of early resolution Identify need for additional services Identify need for additional services

MEDICAL DISABILITY MEDICAL DISABILITY MANAGEMENTMANAGEMENTProper use of vendorsProper use of vendors

Is a nurse case manager assignment Is a nurse case manager assignment appropriate?appropriate?

Any initial red flag (i.e. frequent change Any initial red flag (i.e. frequent change of physician, heavy prescription use, of physician, heavy prescription use, missed appointments, early attorney missed appointments, early attorney involvement)involvement)

Transitional duty return to work failureTransitional duty return to work failure Non cooperative medical provider (i.e. Non cooperative medical provider (i.e.

family doctor?)family doctor?) Injured worker evasive, question extent Injured worker evasive, question extent

of injuryof injury

MEDICAL DISABILITY MEDICAL DISABILITY MANAGEMENTMANAGEMENTAdditional claim management techniquesAdditional claim management techniques

• Subrogation recovery Subrogation recovery • Surveillance – Approved vendors Surveillance – Approved vendors • Carrier In house Special Investigative Carrier In house Special Investigative

Units with established relationships Units with established relationships with local government and NICBwith local government and NICB

• Offsets – Second injury Offsets – Second injury fund/apportionmentfund/apportionment

• LitigationLitigation

CLOSING CLAIM FILESCLOSING CLAIM FILES

Key Elements to Effective Claim Key Elements to Effective Claim ResolutionResolution

Disposition plans that provide a clear and Disposition plans that provide a clear and aggressive strategy, identifying pertinent issues aggressive strategy, identifying pertinent issues and barriers to file closure, plans to resolve those and barriers to file closure, plans to resolve those issues and target date for claim resolution. issues and target date for claim resolution.

Disposition plans are followed and updated Disposition plans are followed and updated continually as information that affects the claim continually as information that affects the claim strategy is obtainedstrategy is obtained

The Ten Commandments of The Ten Commandments of Workers’ CompensationWorkers’ Compensationthou shalt….thou shalt….

The Ten Commandments of The Ten Commandments of Workers’ CompensationWorkers’ Compensationthou shalt….thou shalt….

I. Report Claims Promptly

II. Investigate Every Claim

III. Keep Your Objectivity

IV. Maintain A Relationship With Your Employees

V. Know Your Adjuster(s)

VI. Know Your Docs

VII. Communicate

VIII. Ask And Make Sure You Receive

IX. Maintain a RTW Program

X. Play By The Rules

Questions?Questions?

..brought to you by: ..brought to you by:

SENTRY INSURANCESENTRY INSURANCE

A MUTUAL COMPANY; A+ RATEDA MUTUAL COMPANY; A+ RATED

www.sentry.comwww.sentry.com

STRENGTH-PROTECTION-VIGILANCESTRENGTH-PROTECTION-VIGILANCE

ESTABLISHED 1904ESTABLISHED 1904