Investigating and Handling Suspect Claims

The employer/carrier is to pay only what the law requires, and no more. You are the first line of defense. Your preparation can provide ammunition to win and save you money. Compensation is to be paid for a compensable accident, but only to the extent of the injury caused by the accident. Successful defense of claims depends largely upon the nuts and bolts preparation of investigation, recordation and communication, and on the art of lawyering.

A. Spend Money to Save Money

Defense of compensation cases involves more money and faster turnover than liability cases; key is investigation and preparation.

B. Role of Workers’ Compensation Commission

The Commission rewards defenses which are prepared and proven. It punishes the unprepared by issuing awards that could have been prevented, had all facts been developed before the Commission.

C. Claim Control

Sell Claimant on your concern, fairness, and medical control.

You are the first line of defense. Keep the Claimant advised of his compensation status, i.e., payments and status of medicals. Keep your supervisor and the company informed – no second guessing, no surprises.

You are key to heading off lawyers. If the Claimant feels you are treating him fairly, he is less likely to seek out a lawyer.

D. Medical Control

Provide competent treatment and you may head off lawyers. Treat promptly with goal of returning Claimant to work. Watch out for prolonged treatment and surgery. Keep medical panels current and make sure they are offered to all injured employers.

Use independent medical examiners to evaluate causal relationship in back cases or complicated cases.

Get medical authorization from Claimant in blank. Key to obtaining medical history (doctor and hospital).

Complete medical history aids independently in evaluating Claimant.

E. Average Weekly Wage

Get wage statement from employer, with Claimant’s gross wages from the fifty-two weeks prior to the accident. Once the average weekly wage is decided by a deputy commissioner, rarely will the Commission change this.

Send wage statement to Commission on the required form so there is no error.

F. Limitations Defense

Claimant has two years from date of accident to file claim. In occupational disease cases, two years from the date of diagnosis or last injurious exposure, whichever is later.

Claimant has three years from the date compensation was last paid to file a change in condition application for permanent partial disability benefits.

Claimant has two years from date the compensation was last paid to file a change in condition application for temporary total or temporary partial disability benefits.

No limitations defense if:

1. temporary total paid for sixteen weeks or more;

2. failure to file an Employer’s First Report of Injury for an injury that causes more than seven days lost from work extends the limitations period.

G. Employer’s First Report

Do not complete it based solely on Claimant’s allegations; use your own information. Prepare carefully — can be an admission.

Limitations does not begin to run until report filed.

Retain proof of filing report with Workers’ Compensation Commission — they may lose or misfile it, even when filed electronically.

Back to Workers’ Compensation Resources

In addition to aggressively pursuing defense of our clients’ interests, each spring, we present a free seminar to update employers, insurers, third-party administrators, and others on recent developments in workers’ compensation law. If you wish to be added to the mailing list for next year’s seminar, contact Marilyn N. Harvey.

The Gallery Building Suite 130 5712 Cleveland Street Virginia Beach, VA 23462 Ph: (757) 466-0464 Fax: (757) 466-8242 Email: