Dear Claims Adjuster - Part 1

Saturday, August 13, 2005 | 0

By Peggy Sugarman, Executive Director, VIAW

As the first person who deals directly with injured workers about their claim, you have a lot of influence on the course of the claim; whether it goes smoothly and how quickly things get resolved. For of you who have entered this profession recently, let me tell you that the system has changed enormously.

Now you may love your job, but I very much doubt that any of you ever thought about becoming a workers' compensation claims adjuster when you were pondering your career choices as a child  unlike the doctors and lawyers with whom you interact on a daily basis. You likely obtained this job via a series of fortunate (or, perhaps, unfortunate) decisions. Either way, you play a crucial role in the workers' compensation system. Your views of the system are understandably influenced by your experience and your perception of the role that you play.

In this series, I am hoping to provide a forum for discussion between you and the people for whom I now advocate. I truly believe that with better understanding of ourselves and our motivations we can make positive changes in our lives and the lives of others.

I began my own career in 1977 in the insurance industry when the workplace looked like a scene from "The Apartment" in which Jack Lemmon worked in a cavernous room filled with desks, phones, typewriters, and piles of paper. I had the good fortune to sit next to a seasoned claims examiner, Marian Hoye, who spent so much time fielding calls from injured workers and explaining benefits that she had to scramble to get her payments out on time. She always addressed claimants as "Mr." or "Mrs."

It was a time when prompt 1st payments were a source of pride in the insurance industry and were used as marketing tools to prospective employers; when insurance companies employed benefit counselors who made home visits to injured workers and talked with them about their benefits; when phone calls were answered and claims adjusters had the authority to approve medical treatment that appeared reasonable. A good claims adjuster could resolve disputes, and knew that the best claim was one that was resolved early with the minimum amount of litigation and delay. Sure, there were problems. Some workers were unreasonable in their demands and cases did end up in court. But the goal of getting a case to resolution quickly was always understood.

What happened to those times? Laws changed and became more and more complex. Technology altered the nature of the work so that now you are reachable only via voice mail and email. You likely sit in a cubicle. In essence, you are more cut off from co-workers and from the injured workers and employers whom you serve. Worse, you have more to do and less authority to make decisions on individual case files. This lack of authority and accessibility makes people on the other side angry and unhappy  whether it is the injured worker trying to understand the system, the physician trying to get authorization for medical treatment, the defense attorney trying to get approval for a settlement or the applicants' attorney who wants to get a PD advance to prevent the loss of a home or car. And all of that unhappiness gets directed your way. If you think that it doesn't have an impact on you, better think again. Even the ACOEM Guidelines acknowledge that the lack of job decision latitude is a factor for Cardiovascular disease. (See ACOEM Guidelines, page 26).

In the next edition, I will discuss how workers are affected by the delays and how workers and claims adjusters end up falling into predictable patterns of behavior that are antithetical to the goal of getting workers treated, out of the system, and back to being a productive, tax-paying member of society. In the meantime, feel free to share your thoughts on what I have said so far by emailing me at: psugarman@viaw.org.

Let the dialog begin!

Sincerely,

Peggy Sugarman, Executive Director
VotersInjuredatWork.org

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