Guide to Claims Handling
Presented by: Jason Trujillo, Senior Claim Representative
Items that help with questionable claims:
• Extensive claim investigation
– – – – – Clear, concise, and timely witness statements Pictures Timely notification to Pinnacol Previous medical history Key into employees that know the injured worker.
What are some services that can help with investigation?
• • • • Surveillance Insurance Index Perform hospital and/or pharmacy searches Write letters to the treating doctors to address concerns
Continued…
• Request independent medical examinations • Speak directly with treating providers (Only if the injured worker is not represented) • Request medical history from the injured worker.
What can our policy holder do to help control the claim costs?
• • • • Focus on accident investigation Early claim reporting RTW and Safety Program Open communication with the claims representative, medical providers and injured worker.
What are some signs that indicate permanency or delayed recovery?
• At least 6 months of medical treatment with no improvement • Surgery • Functional Capacity Evaluation • Injured worker is not cooperating
How does your provider respond to questionable cases?
• Key phrases in medical reports • Review and respond to surveillance video and letters • Review independent medical examinations
How do claimant attorneys effect the cost of the claim?
– Increased impairment ratings due to the injured worker going through the DIME process – Increased medical costs
– Legal expenses for litigation on issues
Tying it All Together
• If we all work together we can make sure that workers’ comp claims are handled efficiently and appropriately.
• Questions