2. NJ RIMS Chapter NJ RIMS Chapter Risk Management Day November 10 th 2009 Sentry Insurance Pamela Pezewski Senior Claims Specialist

3. THE BASICS OF WORKERS’ COMPENSATION & AGGRESSIVE CLAIM MANAGEMENT

4. COMPENSABILITY WHAT ARE THE REQUIREMENTS OF 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 employment? Did the incident occur in the course of employment? Did it arise out of employment? Did it arise out of employment? Is there causal Relationship established? Is there causal Relationship established?

5. WAS THERE AN ACCIDENT WITH INJURIES? ACCIDENT- an unexpected event that results in injury. ACCIDENT- an unexpected event that results in injury. INJURY – Any change in the body that produces harm, pain, or decreased capacity for the body to function. An injury need not involve physical trauma but may include mental trauma. Injury may or may not be of traumatic nature; and could occur over time which we refer to as an occupational exposure. INJURY – Any change in the body that produces harm, pain, or decreased capacity for the body to function. An injury need not involve physical trauma but may include mental trauma. Injury may or may not be of traumatic nature; and could occur over time which we refer to as an occupational exposure.

6. COURSE AND SCOPE Injury must occur during the employment period. Injury must occur during the employment period. It must occur where the employee is reasonably expected to perform their work activities. It must occur where the employee is reasonably expected to perform their work activities. The employee must be fulfilling their duties, or engaged in an activity related to their duties, or performing an activity for the betterment of their employer. The employee must be fulfilling their duties, or engaged in an activity related to their duties, or performing an activity for the betterment of their employer.

7. ARISE OUT OF EMPLOYMENT A compensable injury must be caused by an activity related to the employee’s job duties. An activity is related to the employment if it carries out the employer’s purpose or advances the employer’s interests either directly or indirectly. A compensable injury must be caused by an activity related to the employee’s job duties. An activity is related to the employment if it carries out the employer’s purpose or advances the employer’s interests either directly or indirectly. The person’s work need NOT be the primary cause of the accident. If the employment and personal risks merge together to produce an injury, that injury will generally be held to have arisen from employment. The person’s work need NOT be the primary cause of the accident. If the employment and personal risks merge together to produce an injury, that injury will generally be held to have arisen from employment.

8. CAUSAL RELATIONSHIP If there was an accident, are the injuries claimed resultant of the accident? If there was an accident, are the injuries claimed resultant of the accident? Diagnosis? Diagnosis? Is it medically possible/probable for the work environment to have caused the medical problem? Is it medically possible/probable for the work environment to have caused the medical problem? Is it medically possible/probable that the medical problem is a result of personal life? Is it medically possible/probable that the medical problem is a result of personal life? Did this condition pre-exist the work incident/injury? Did this condition pre-exist the work incident/injury? Did we aggravate this pre-existing condition? Temporarily and/or permanently? Did we aggravate this pre-existing condition? Temporarily and/or permanently?

9. Time to play: 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 punched the wall… The machine jammed and it made me mad and I punched the wall… I forgot to take my insulin and fainted and hit my head on my desk… I forgot to take my insulin and fainted and hit my head on my desk… Instead of going down the stairs I jumped off the loading dock… Instead of going down the stairs I jumped off the 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 him up a the newspaper and I slipped and fell… I was running an errand and my boss asked me to pick him up a the newspaper and I slipped and fell… I was lifting weights in our company gym during my break and hurt my shoulder I was lifting weights in our company gym during my break and hurt my shoulder

10. Benefits of timely reporting? Lock in accident facts Lock in accident facts Lock in body part Lock in body part Preserve evidence Preserve evidence Descriptions of accidents are like fish stories…the more time passes the bigger the fish… Descriptions of accidents are like fish stories…the more time passes the bigger the fish…

13. INVESTIGATION Gather all pertinent facts – who, what, when, where, and how. Gather all pertinent facts – who, what, when, where, and how. Determine injury/diagnosis as it relates to accident to determine causal relationship. Determine injury/diagnosis as it relates to accident to determine causal relationship. Profile the medical history. Priors? Pre- existing medical conditions? Profile the medical history. Priors? Pre- existing medical conditions? Is there opportunity for subrogation? Second injury fund? Apportionment? Is there opportunity for subrogation? Second injury fund? Apportionment?

14. Common Frustrations We pay for carelessness! We pay for carelessness! Aggravation of a pre-existing condition is covered Aggravation of a pre-existing condition is covered Workers’ compensation laws are written to the benefit of the employee Workers’ compensation laws are written to the benefit of the employee A problem employee will probably be a problem claimant. A problem employee will probably be a problem claimant.

15. BENEFITS WAGE 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) MEDICAL MEDICAL VOCATIONAL RETRAINING VOCATIONAL RETRAINING

16. MEDICAL/DISABILITY MANAGEMENT KEYS TO SUCCESSFUL MEDICAL/DISABILITY MANAGEMENT - Prompt reporting to Carrier -Employer to assist with medical care -Ongoing communication -Early identification of problems -Aggressive use of transitional work -Proper utilization of vendors -Keep supervisors informed KEYS TO SUCCESSFUL MEDICAL/DISABILITY MANAGEMENT - Prompt reporting to Carrier -Employer to assist with medical care -Ongoing communication -Early identification of problems -Aggressive use of transitional work -Proper utilization of vendors -Keep supervisors informed

17. MEDICAL/DISABILITY MANAGEMENT EMPLOYER DUTIES: Promptly report the injury Promptly report the injury Timely onsite investigation Timely onsite investigation Ensure medical assistance Ensure medical assistance Communicate with the injured worker Communicate with the injured worker Offer transitional work Offer transitional work Secure weekly status updates Secure weekly status updates

18. MEDICAL/DISABILITY MANAGEMENT CARRIER ROLE: Indemnify injured worker Indemnify injured worker Ongoing proactive case management Ongoing proactive case management Keep all parties informed Keep all parties informed Biweekly contact with injured worker Biweekly contact with injured worker Strategize for early return to work Strategize for early return to work Assure forward direction of case in support of early resolution Assure forward direction of case in support of early resolution Identify need for additional services Identify need for additional services

19. MEDICAL DISABILITY MANAGEMENT Proper use of vendors Is a nurse case manager assignment appropriate? Is a nurse case manager assignment appropriate? Any initial red flag (i.e. frequent change of physician, heavy prescription use, missed appointments, early attorney involvement) Any initial red flag (i.e. frequent change of physician, heavy prescription use, missed appointments, early attorney involvement) Transitional duty return to work failure Transitional duty return to work failure Non cooperative medical provider (i.e. family doctor?) Non cooperative medical provider (i.e. family doctor?) Injured worker evasive, question extent of injury Injured worker evasive, question extent of injury

20. MEDICAL DISABILITY MANAGEMENT Additional claim management techniques Subrogation recoverySubrogation recovery Surveillance – Approved vendorsSurveillance – Approved vendors Carrier In house Special Investigative Units with established relationships with local government and NICBCarrier In house Special Investigative Units with established relationships with local government and NICB Offsets – Second injury fund/apportionmentOffsets – Second injury fund/apportionment LitigationLitigation

21. CLOSING CLAIM FILES Key Elements to Effective Claim Resolution Disposition plans that provide a clear and aggressive strategy, identifying pertinent issues and barriers to file closure, plans to resolve those issues and target date for claim resolution. Disposition plans that provide a clear and aggressive strategy, identifying pertinent issues and barriers to file closure, plans to resolve those issues and target date for claim resolution. Disposition plans are followed and updated continually as information that affects the claim strategy is obtained Disposition plans are followed and updated continually as information that affects the claim strategy is obtained

22. The Ten Commandments of Workers’ Compensation 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

23. Questions?

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