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Trends in Workers' Comp

This One Change Improved Outcomes Tenfold for Travelers’ Workers’ Comp Claims

Connecting injured workers with claims and case professionals of similar backgrounds can alleviate misunderstandings that delay recovery.
By: | September 14, 2018 • 6 min read

Want to keep your workers’ compensation claims from sliding off the rails? Start with case managers and claims adjusters who look, think and talk like their clients.

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Four years ago, Travelers started its Cultural Advantage program. The program hires Hispanic adjusters and nurse case managers to more closely mirror the populations it serves. The initiative produced a 24 percent improvement in injured workers returning to work within 30 days and a 23 percent reduction in attorney representation, said Chris Nixon, senior vice president, claim field management, Travelers.

Often, he said, the conversation begins in English, and as the rapport develops, the injured worker or case manager will ask, ‘Do you speak Spanish?’ “When the response is ‘Yes,’ the conversation transitions into Spanish, and the connection flows from there.”

In Travelers’ Southern California office, a third of claims and case professionals are bilingual, he said, and most speak Spanish, but the program seeks to establish “a cultural connection beyond simple language translation” by matching case and claims managers with injured workers from a similar language and culture.

“Sharing a background provides a more personal connection,” he said, which is a “key to establishing sincere upfront trust.”

All About Trust

The success of a claim depends on trust between the client and case manager, said Jose Alejandro, director of care management, UC Irvine Health and president-elect, Case Management Society of America. In his 25 years in health care, he said, “claims seldom go to litigation when that relationship is trusting, open and collaborative.”

Jose Alejandro, director of care management, UC Irvine Health

Trust depends on common language and cultural understanding, if not actual common culture, Alejandro said. If a case manager or claims adjuster tells an injured worker “these are the three things I need you to do,” he said, that command — an emotionally neutral statement when the case manager and injured worker understand and trust each other — could be received as officious, bullying or arrogant if issued without medical context or regard to cultural considerations.

The worker, offended and confused, could refuse to cooperate. “What should be quick and easy could then take a long time and use a lot of resources.”

Darrell Brown, chief claims officer, Sedgwick, breaks down what “trust” means in the workers’ compensation context. “Manage expectations about the process and how long it will take. Establish what to expect from the client and what the client can expect from us. Understand the family’s needs.”

Which means, he said, address the urgent financial and logistical worries during convalescence: How will I pay the rent? Buy food? Make car payments? Get the kids to school?

Those concerns can be overwhelming, especially for people who already feel marooned in a strange and perplexing world where they don’t speak the dominant language.

“Nurse case managers and claims examiners need to be able to hold clients’ hands through the process, navigating around barriers and interpreting the strange rules,” Brown said.

Alejandro, who holds a nursing degree and was once a claims manager himself, recalls when his own Hispanic cultural experience rescued a two-year-old workers’ compensation claim for a burn to the claimant’s hands and arms. The claim had exhausted all appeals — and the multiple claims managers who had already tried and failed to set it right.

Alejandro flew in to meet the client. After going with her to medical appointments and speaking to the claims manager, he located the disconnect: miscommunication about the outcome the physician wanted, what the claims manager wanted her to do, and what the client understood them to say.

“No one was on the same page,” he said.

“[Good diversity training] sets the expectation that groups are different, that you can’t expect a good outcome when you treat everyone the same. A broken leg isn’t just a broken leg.” — Jose Alejandro, director of care management, UC Irvine Health

Part of the problem was language. “Hiring a translator didn’t bridge the gap between speaking and medical language around prognosis, protocols and timeframes,” Alejandro said. “She was extremely frustrated about not being able to understand the medical pieces and how they impacted her quality of life and return to work.”

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She also felt intimidated by the doctors and case managers, who seemed to hold all the power and who failed to adequately explain why they were asking dozens of personal questions.

Alejandro collaborated with the physician and claims adjuster on a treatment plan. “We broke the process down and walked through it again, slowly at first” while Alejandro worked to win the client’s trust, which wasn’t assured despite their cultural similarities. Within 190 days, she returned to work, not pain-free, but pain-managed. “That’s what she wanted, to return to work.”

The eventual success, he said, depended on a functioning triad model: health care providers, claims adjuster and claims manager working with the client to get through the process. The missing ingredient, before his assignment to the case, had been a claims manager capable of understanding the client’s language and representing her expectations and desired outcome accurately.

1:1 Cultural Match Not Necessary

While similarity between large and disparate cohorts — Hispanic to Hispanic, African American to African American, for example — can grease the communication and cultural wheels, an exact match — Portugese to Portugese in an area with a small Portugese population, for example — is often neither practical nor necessary.

Diversity and inclusion training, including a deep dive into the culture and demographics of its clients, helps bridge the gap, Brown said. “When I call a bank or airline, I’m looking for the most capable person to help me,” which isn’t necessarily a cultural match.

Darrell Brown, chief claims officer, Sedgwick

Good diversity training, said Alejandro, addresses the principles of working with different groups, regardless of what the group is. “It sets the expectation that groups are different, that you can’t expect a good outcome when you treat everyone the same. A broken leg isn’t just a broken leg.”

Travelers takes training seriously, said Fred Colon, chief diversity and inclusion officer, starting with a commitment from top leadership. A robust program that produces measurable results in duration of claims, reduced litigation and claims spend, he said, involves a lot of time, thought and resources.

Travelers commits a half-day workshop with live trainers at every employee’s hire, and the principles the training covers affect every aspect of the company’s brand, recruitment, professional development and retention.

Although Travelers’ bilingual hiring concentrates on serving Hispanic-Americans, the country’s largest minority at nearly 60 million, according to a Simmons Market Research survey, training “should capture diverse religions, geography, location, cultures, sexual orientation and political points of view, among other things,” said Colon.

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Even the most diverse claims and case management populations need training, said Brown, the executive sponsor of Sedgwick’s inaugural diversity and inclusion council. He describes a soul-baring aspect to its training.

Sedgwick’s very diverse workforce “has a lot to teach each other” about unconscious bias, Brown said. “I thought I was open-minded and empathic, but there was so much I didn’t know about what working mothers deal with, taking care of children, among others.”

Working mothers are just one of the groups that can evade many people’s radar screens. “You need all those voices at the table to bring their experiences and perspectives,” Brown said.

That personal revelation ties directly to claims outcomes, he said. Anything can go wrong: the patient doesn’t like the doctor, doesn’t agree with the return-to-work plan, skips appointments. Payment may be delayed for perfectly legitimate reasons.

“Appreciating differences makes you a better case manager. Workers litigate because the process is foreign and they fear termination,” he said. “We have a role in mitigating that. We put our understanding of differences to work.” &

Susannah Levine writes about health care, education and technology. She can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

High Net Worth

High Net Worth Clients Live in CAT Zones. Here’s What Their Resiliency Plan Should Include

Having a resiliency plan and practicing it can make all the difference in a disaster.
By: | September 14, 2018 • 7 min read

Packed with state-of-the-art electronics, priceless collections and high-end furnishings, and situated in scenic, often remote locations, the dwellings of high net worth individuals and families pose particular challenges when it comes to disaster resiliency. But help is on the way.

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Armed with loss data, innovative new programs, technological advances, and a growing army of niche service-providers aimed at addressing an astonishingly diverse set of risks, insurers are increasingly determined to not just insure against their high net worth clients’ losses, but to prevent them.

Insurers have long been proactive in risk mitigation, but increasingly, after the recent surge in wildfire and storm losses, insureds are now, too.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy,” said Laura Sherman, founding partner at Baldwin Krystyn Sherman Partners.

And especially in the high net worth space, preventing that loss is vastly preferable to a payout, for insurers and insureds alike.

“If insurers can preserve even one house that’s 10 or 20 or 40 million dollars … whatever they have spent in a year is money well spent. Plus they’ve saved this important asset for the client,” said Bruce Gendelman, chairman and founder Bruce Gendelman Insurance Services.

High Net Worth Vulnerabilities

Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

As the number and size of luxury homes built in vulnerable areas has increased, so has the frequency and magnitude of extreme weather events, including hurricanes, harsh cold and winter storms, and wildfires.

“There is a growing desire to inhabit this riskier terrain,” said Jason Metzger, SVP Risk Management, PURE group of insurance companies. “In the western states alone, a little over a million homes are highly vulnerable to wildfires because of their proximity to forests that are fuller of fuel than they have been in years past.”

Such homes are often filled with expensive artwork and collections, from fine wine to rare books to couture to automobiles, each presenting unique challenges. The homes themselves present other vulnerabilities.

“Larger, more sophisticated homes are bristling with more technology than ever,” said Stephen Poux, SVP and head of Risk Management Services and Loss Prevention for AIG’s Private Client Group.

“A lightning strike can trash every electronic in the home.”

Niche Service Providers

A variety of niche service providers are stepping forward to help.

Secure facilities provide hurricane-proof, wildfire-proof off-site storage for artwork, antiques, and all manner of collectibles for seasonal or rotating storage, as well as ahead of impending disasters.

Other companies help manage such collections — a substantial challenge anytime, but especially during a crisis.

“Knowing where it is, is a huge part of mitigating the risk,” said Eric Kahan, founder of Collector Systems, a cloud-based collection management company that allows collectors to monitor their collections during loans to museums, transit between homes, or evacuation to secure storage.

“Before, insurance was considered the only step in risk management. Now, our client families realize it is one of the many imperative steps in an effective risk management strategy.” — Laura Sherman, founding partner, Baldwin Krystyn Sherman Partners

Insurers also employ specialists in-house. AIG employs four art curators who advise clients on how to protect and preserve their art collections.

Perhaps the best known and most striking example of this kind of direct insurer involvement are the fire teams insurers retain or employ to monitor fires and even spray retardant or water on threatened properties.

High-Level Service for High Net Worth

All high net worth carriers have programs that leverage expertise, loss data, and relationships with vendors to help clients avoid and recover from losses, employing the highest levels of customer service to accomplish this as unobtrusively as possible.

“What allows you to do your job best is when you develop that relationship with a client, where it’s the same people that are interacting with them on every front for their risk management,” said Steve Bitterman, chief risk services officer for Vault Insurance.

Site visits are an essential first step, allowing insurers to assess risks, make recommendations to reduce them, and establish plans in the event of a disaster.

“When you’re in a catastrophic situation, it’s high stress, time is of the essence, and people forget things,” said Sherman. “Having a written plan in place is paramount to success.”

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Another important component is knowing who will execute that plan in homes that are often unoccupied.

Domestic staff may lack the knowledge or authority to protect the homeowner’s assets, and during a disaster may be distracted dealing with threats to their own homes and families. Adequate planning includes ensuring that whoever is responsible has the training and authority to execute the plan.

Evaluating New Technology

Insurers use technologies like GPS and satellite imagery to determine which homes are directly threatened by storms or wildfires. They also assess and vet technologies that can be implemented by homeowners, from impact glass to alarm and monitoring systems, to more obscure but potentially more important options.

AIG’s Poux recommends two types of vents that mitigate important, and unexpected risks.

“There’s a fantastic technology called Smart Vent, which allows water to flow in and out of the foundation,” Poux said. “… The weight of water outside a foundation can push a foundation wall in. If you equalize that water inside and out at the same level, you negate that.”

Another wildfire risk — embers getting sucked into the attic — is, according to Poux, “typically the greatest cause of the destruction of homes.” But, he said, “Special ember-resisting venting, like Brandguard Vents, can remove that exposure altogether.”

Building Smart

Many disaster resiliency technologies can be applied at any time, but often the cost is fractional if implemented during initial construction. AIG’s Smart Build is a free program for new or remodeled homes that evolved out of AIG’s construction insurance programs.

Previously available only to homes valued at $5 million and up, Smart Build recently expanded to include homes of $1 million and up. Roughly 100 homes are enrolled, with an average value of $13 million.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work.” — Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“We know what goes wrong in high net worth homes,” said Poux, citing AIG’s decades of loss data.

“We’re incenting our client and by proxy their builder, their architects and their broker, to give us a seat at the design table. … That enables us to help tweak the architectural plans in ways that are very easy to do with a pencil, as opposed to after a home is built.”

Poux cites a remote ranch property in Texas.

Curt Goetsch, head of underwriting, Private Client Group, Ironshore

“The client was rebuilding a home but also installing new roads and grading and driveways. … The property was very far from the fire department and there wasn’t any available water on the property.”

Poux’s team was able to recommend underground water storage tanks, something that would have been prohibitively expensive after construction.

“But if the ground is open and you’ve got heavy equipment, it’s a relatively minor additional expense.”

Homes that graduate from the Smart Build program may be eligible for preferred pricing due to their added resilience, Poux said.

Recovery from Loss

A major component of disaster resiliency is still recovery from loss, and preparation is key to the prompt service expected by homeowners paying six- or seven-figure premiums.

Before Irma, PURE sent contact information for pre-assigned claim adjusters to insureds in the storm’s direct path.

“In the high net worth space, sometimes it takes longer potentially to recover, simply because there are limited contractors available to do specialty work,” said Curt Goetsch, head of underwriting for Ironshore’s Private Client Group.

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“If you’ve got custom construction or imported materials in your house, you’re not going to go down the street and just find somebody that can do that kind of work, or has those materials in stock.”

In the wake of disaster, even basic services can be scarce.

“Our claims and risk management departments have to work together in advance of the storm,” said Bitterman, “to have contractors and restoration companies and tarp and board services that are going to respond to our company’s clients, that will commit resources to us.”

And while local agents’ connections can be invaluable, Goetsch sees insurers taking more of that responsibility from the agent, to at least get the claim started.

“When there is a disaster, the agency’s staff may have to deal with personal losses,” Goetsch said. &

Jon McGoran is a novelist and magazine editor based outside of Philadelphia. He can be reached at [email protected]