Adjuster X

The Rejection Demand

By: | March 2, 2015 • 3 min read
This column is based on the experiences of a group of long-time claims adjusters. The situations they describe are real, but the names and key details are kept confidential. Michelle Kerr is the editor of this column and can be reached at [email protected]

“You are not going to accept this claim, do you quite understand?” said Sumar Sanji, the CEO of Centerville Fuel, speaking rather forcefully.

“Mr. Sanji,” I replied, “you have made yourself abundantly clear. The investigation is underway. I need to come down and go over everything with you.”

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“Very well,” Sanji replied. “Make haste. I shall explain all.”

Fred Sanders, 29, had been driving for Centerville Fuel for three years. He broke his right arm in a one-vehicle accident while driving a company truck. I visited him before meeting Sanji.

Sanders lived in a modest single-story home. His right arm was casted. “What caused the accident?” I asked him.

The claim seemed simple. So why did Sanji want to deny it?

“The road was wet,” he said. “I was going downhill within the speed limit, and the truck skidded off the road. There was nothing wrong with the truck — it was new. It was just an accident. My arm hurts like heck and I’m right-handed.”

Reviewing the time of the accident and his location, I saw no indication that Sanders had deviated from his route. The claim seemed simple. So why did Sanji want to deny it?

I didn’t have to wait long to find out. “This is a fraud,” Sanji opened our meeting with. “Fred Sanders was a double agent!”

Baffled, I asked, “Was he not driving your truck to your customer’s location when the accident occurred?”

Sanji waved a small book in the air. “He was working for another company. We found this in the truck following the accident.” I looked at Sanji quizzically.

He continued, “FDOT regulations require that truck drivers log their road time. There were two logs in the truck. One was for Centerville Fuel, but this one was for Aias Systems. Sanders was working for another company while he drove my truck! And the truck he damaged was brand new. The accident was his fault! Why should he be able to recover under my workers’ comp policy?”

I slowly replied, “Mr. Sanji, you have given two reasons why you believe this claim should be denied. The first is that Sanders was concurrently employed by another company while working for you. The second is that the accident was entirely the fault of Sanders.” Sanji nodded.

“The fact is that Sanders may well have been working for both you and Aias Systems. But on the date of the accident he was driving from your plant to your customer’s location, along a direct route. He was in the course and scope of his employment for Centerville Fuel when the accident transpired.”

“But Aias Systems should also be held accountable!” Sanji protested.

“Not unless we can prove Sanders was somehow in the course and scope of employment for Aias when the accident occurred, or that Aias benefited from Sanders visiting your client,” I countered. “Let’s move on.”

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“You say that the accident was Sanders’ fault. That may be entirely true. However, workers’ comp is no-fault. Negligence on the part of the employee does not bar recovery under workers’ comp.”

Sumar Sanji looked aghast. “This man is guilty of fraud and reckless driving. Benefits should not be extended to him under my policy.”

“Mr. Sanji, there’s no way to sustain a denial of workers’ comp benefits on this claim. If you want to discipline Sanders for moonlighting, that’s up to you, but it will not mitigate your exposure for the arm injury.”Adjuster

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

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That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

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Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]