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Claims tip: Missed steps cost employer over $50,000
By Teresa Long

The claim: Employee reported to work limping and within the following week reported an injury lifting a pan that weighed less than four pounds. The claim has paid almost $80,000 in benefits arising from a back injury. The problem: it didn't happen on the job. Or, in the worst-case scenario, was a very minor aggravation of a pre-existing injury that would have lasted a week or two and resolved.

The analysis: Where did the employer miss the proverbial 'boat'? There was suspicion that the employee was hurt off the job and a diligent investigation rounded up all the supervisors and found mainly hearsay that the employee has a private business at a farmer's market and other high level activity. Not really enough for the adjuster to justify a full denial of the claim. Almost a year later, it was discovered, at an unrelated meeting, that there was one person (not interviewed in the original investigation) who was not a supervisor but a co-worker who saw the allegedly injured employee come into work limping and complaining of a hurt back from his 'other job'.

The lessons: Hindsight being 20/20, two lessons:

  1. The investigation boat was loaded only with supervisors and the one person who had first-hand knowledge was not identified. Don't stop with just the obvious - supervisor knowledge - dig deeper to find anyone who may have pertinent information. The opportunity was missed for a full denial and subsequently over $50,000 paid in benefits.
  2. Preventative lesson - why not consider asking injured employees at the time the injury is reported: "Before today, have you had any personal injuries, illnesses or conditions that could be causing or increasing your current level of pain?" However you want to phrase the question, ask and give the employee an opportunity to be honest and tell you about any injury he had playing soccer over the weekend, for instance. If it is both a verbal and written question, make sure the question is strategically placed near to one of your Anti-Fraud pictures/statements of zero tolerance for on the job fraud. If you don't ask, you might not know until it's too late.

Teresa A. Long is Director of Injury Management Strategies for the Institute of WorkComp Professionals, which trains insurance agents to help employers reduce Workers' Compensation expenses and of which we are a member.Teresa was claims manager for 14 years for Walt Disney World and later was Regional Operations Manager for Alternative Service Concepts.