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Old Game . . . New Player

By Denise Vega - July 2, 2002

Whenever the economy tanks, employers rush to limit their workers’ compensation costs. As benefit dollars mount, businesses flock to anyone offering a quick fix. Cottage industries, selling questionable programs guaranteed to win the comp war, multiply like toadstools after a spring rain.

Recently I met the principal of such an operation. This individual had zero claims experience. Nevertheless, a career in law enforcement and some law school empowered this person to proclaim himself as, “The Work Comp Guru.”

This self-appointed sage dangled the glittering prospect of reduced comp dollars if the employer hired him to oversee their claims. The Guru spoke of “derailing the claims process” by taking a “sledgehammer to the adjusters.” The Appeals Board must be “manipulated” to serve the employer, not the worker. Underwriters must be “forced to pay” for services, which the employer could secure through the Guru, he proclaimed.

When asked how these stratagems translated into practical application, the Guru spouted a litany of vagueness. Pressed for specifics the Guru suggested that if an adjuster refused subrosa authorization, the employer must secure its own. This would give the guru the opportunity to spring on the court what evidence he gathered on behalf of the employer the day of trial. I pointed out that Board rules required disclosure of all evidence at the time of the MSC. My comment irked the Guru for I received a rather testy reply.

“We associate in the employer as a third party after the MSC and get it in that way,” said the Guru.

“But an employer may be dismissed once an insurer admits coverage,” I explained.

“Well yes, but only on a motion,” the Guru argued.

“A judge can order the dismissal on their own motion. What happens then?,” I inquired.

The Guru stared at the conference table and mumbled, “Well, I admit it is a risky proposition.”

“And if the tapes are not admitted, that means the employer has spent $2000 or $4000 for nothing?”

Annoyed that I made this remark, the Guru ignored me and told the employer, “You see we demand that the underwriter pay for the surveillance.”

“Excuse me,” I interjected, “But just how are you going to force underwriting to pay for something the examiner didn't order?”

The Guru responded sternly, “We tell the underwriter that the adjuster failed to properly defend the claim. Then we threaten a bad faith suit.”

I then asked, “And who is going to pay for the expenses for this suit? The employer may pay $10,000 in legal fees in hopes that they might recoup $2000.”

I noted that the arrogance present at the on-set of the presentation had been replaced by indignation. Obviously vexed, the Guru offered some proposals about “analyzing” the employer's current program and left to find a more receptive client.

This individual represents but one of a growing number of such firms selling questionable tactics to any employer willing to listen. They offer to reduce expenses by taking aim at the easiest target, the claims examiner. Lacking technical expertise, they utilize the claims review as an opportunity to go for the adjuster’s jugular.

Having sat on both sides of the review process, I know that such attitudes create animosity, not solutions. Too many of those who call themselves experts, hold strong, but impractical opinions on how to overturn the system. Seldom do they offer realistic advice on how to work within the legal confines. Inevitably they fail to grasp that work comp involves a simple endeavor . . . delivering benefits to injured workers while protecting the employer's interests. Such individuals believe that all workers lie; that all employers are railroaded by the system and that alladjusters are incompetent.

The claims examiner facing these individuals confronts a troubling dilemma. How does one maintain a courteous, professional manner while resisting the impulse to shove a claim file up an arrogant nostril?

Truth is always the best defense. Arrive at the claims review prepared to discuss files in a detached manner, providing legal facts and cost figures. Eliminate emotion when detailing the vagaries of the individual claim. Explain your strategy based upon your knowledge of the physicians, attorneys and judges. Clearly detail the realities of the Appeals Board and Rules and Regulations. Know what is possible and what is windmill tilting.

Most importantly, continue to educate yourself on the work comp world. Knowledge always overcomes the speculations of those who seek to disparage the adjuster work. With constant updating of skills, a claims technician forges the armor that insulates them for the wild accusations and unrealistic demands of the ill informed.

Whenever I prevailed at some new claim strategy I would joke that the score stood somewhere around, “Christians 3, lions 600.” At this difficult time in the work comp cycle, the arena seems filled with hungry lions seeking to feed off the system. But, being forewarned is to be forearmed. The seemingly ferocious beasts can be tamed into something closer to toothless kittens.

Denise Vega offers a unique perspective to readers. From the vantage point of 30 years in both the insured and self-insured communities, she said, “I’ve seen all the players who have come an gone.”

She has worked as a hearing rep, claims examiner and currently operates her own consulting practice called Resolution Association.


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