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Here's how to manage a successful workers comp claim

Workers’ compensation claims occur on a regular basis, but how the adjuster manages the case from the outset can often determine whether the employee returns to work or becomes a client of Dowe, Sueum and Howe. Consider the following case study and see how small but important decisions throughout the process created an outcome in everyone’s best interests.  

John, a machinist, arrives at work at 7:00 a.m., clocks in and meets with his co-workers in the break room. Nothing unusual about today, but he hasn’t begun to work yet either.

After donning his proper personal protective equipment, John turns on his machine and begins to mill the first of 50 or so parts slated for his production run that day. After completing the first 30 parts, John removes a milled part, but as he begins to pull it from the chocks, a small piece of metal shaving rubs the topside of his long, ring and small fingers of his right hand.

As it ran through the machine, this last part left a ribbon of metal shaving the thickness of a razor blade just high enough to rub the fingers of his hand. John was wearing his cotton work gloves and thought it couldn’t be more than a scratch. As he puts the part down, he notices a wet feeling on the tips of his fingers and sees blood when he takes off his gloves. 

He reports this to his supervisor, who calls his health and safety executive (HSE) representative. While John washes his hand, his supervisor, Bill, gets bandages from the first aid kit. The HSE representative calls the adjusting firm that assists with their injured employees and Steve, an adjuster, is dispatched to the site. It seems like a small cut into the fingers, a little deep, but just a very thin slice. John is bandaged and the adjuster arrives. There is no indication that this injury did not occur at the jobsite in the course of John’s work duties.

Brief introductions are made and Steve asks John how he’s feeling. John responds, “Okay. I cleaned it up and Bill bandaged me up pretty good.” 

Steve then asks what happened and John describes the incident. Because of Steve’s experience, he knows there is a chance that John’s injury may be more significant than just a superficial cut. Steve asks John to straighten out his fingers, but he cannot and describes some pain associated with attempting to move them as requested. Based on Steve’s experience, he calls the doctor and the hand specialist, and reports to the doctor the nature of the injury with a description of the range of motion that John cannot display. The doctor instructs Steve to bring John into his clinic. 

Along the way, Steve outlines to John what will occur that day, answers any questions, and explains why he called Dr. Hinderling, an orthopedic hand specialist. Steve also called the drug screening company and arranged to have a representative meet them at the doctor’s office. While John and Steve fill out the administrative paper work for the doctor, Steve presents and reviews a medical authorization form with John.

After the examination, the doctor informs John that he actually has severed the extensor tendon of the ring finger and slightly damaged the same tendon of the small and long fingers of his dominate right hand. After making the arrangements to have the repair to John’s hand completed, Steve has enough time to obtain John’s recorded statement (provided John is not on any narcotic pain medication). He also provides John with a wage and employment authorization. 

Steve has completed the initial phase of the investigation factually, compressed the time that John will be out of work by directing the medical care, and reduced any lost time as light or modified duty as available. Dr. Hinderling understands the emotional and psychological well-being of the injured employee and is extremely cooperative about having John return to work in some capacity, albeit with little use of his right hand. 

Because Hinderling is eminently qualified, John is more than satisfied with the physician chosen by the adjuster and agrees to select Hinderling as his treating physician by signing a choice of physician form (if the state requires such a provision) at the first surgical follow up appointment. Surgery is performed that day and John is on his way to recovery. He will likely reach maximum recovery and return to full duties and be discharged from medical care in eight to 12 weeks. 

Steve can return to the facility to interview witnesses to determine other facts that may or may not lead to subrogation possibilities or at a minimum work with the HSE department to develop possible changes in procedure to lower the risk of a similar event. 

John returns to work, fully recovered and with no residual disability. Because the authorizations have been signed, Steve can fully investigate any prior medical issues that might have an impact on the claim and any background information from prior employers should that become necessary.

John is thrilled that as serious as the injury was, his company treated him as a person and not a problem to manage, and used the necessary means to have him seen by a competent specialist immediately. He was able to return to work, continue on full pay and not have reduced wage replacement through temporary total disability payments.

Steve’s involvement from the outset, his empathy for John, being there for him throughout the process, his experience in understanding John’s injury and having the authority to act on it, allowed John to perceive Steve as an advocate. At the same time, Steve had the ability as a licensed adjuster to investigate the claim and the circumstances surrounding the injury. 

Since Steve has met with the doctor previously and knows him, they can exchange information about the nature and extent of the injury immediately, not three weeks later when the report and bill are issued. Steve can ask the doctor questions related to John’s injury and recovery, and gain feedback that is useful in getting John back to work sooner, heading off any reluctance on John’s part about returning to work even on a diminished capacity. Steve’s involvement can quickly identify any change in John’s attitude and adjustments can be made to bring the matter to a conclusion.

These are the common stories, especially when companies take the initiative to set up a process that involves a professional outside field adjuster from the outset. The medical professionals have already been put in place because the adjusting firm has developed a network of physicians in various specialties to address injuries that occur within the workplace. This often eliminates the need to involve more than one doctor, and the injured employee is almost taken aback by the personal attention delivered to him to address his injury. 

A real overall big picture analysis is better to determine the cost benefits associated with such an approach. John didn’t need to go to a doctor to get a referral to a specialist, and more than likely, eliminated a four or five-hour emergency room visit. If the E.R. could line up a surgeon that day, everyone is now at their mercy. This deteriorates into not just a severed extensor tendon of the right ring finger, but before it’s over, John could develop some permanent issue that requires extensive therapy, more medical treatment and requires the carrier to schedule an independent medical exam with a physician. 

There is an increased possibility that the entire claim could transform John into a plaintiff as well as a permanent patient instead of a productive member of society who can support his family. In the second scenario, John loses his dignity, since the lawsuit could be a multi-year process, and the company loses an otherwise productive employee; trading him for an embittered plaintiff for Dowe, Sueum and Howe.

Robert L. Judge is the founder of R. L. Judge & Associates, LLC, a claims investigation and risk management firm.


At Prime Insurance Agency, we can work with you to make sure you've got the coverage you need, while at the same time using all possible credits and discounts to make that coverage affordable.

Call us at 732-886-5751 or send us a note at . We want to help you meet your goals, and make sure what's important to you is protected!


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