Moore: Personal Sensitivity Claims: Frustrating for Employees and Adjusters

Wednesday, September 26, 2018 | 0

A large number of personal sensitivity claims have created a large chasm between workers' compensation adjusters and employees who report this type of claim.   

James Moore

General sensitivity claims can be defined as where the employee reports a claim that may have been caused by exposures that the general public faces and are not specific to the job.   

The maddest employees with the smallest workers' comp claims come into play when adjusters assess a claim — usually medical-only claims — as not being specific to the risks of the employee’s job.   

The best examples:

• Part of an employee’s job involves washing down a workspace. The cleaner used is nothing more than soap and warm water.   
• The employee reports a claim that the soap irritated his hands and caused a rash on his arms.   
• The employee seeks medical treatment for the irritation and rash.
• The medical-only adjuster receives the first report of injury.   
• The medical-only or lost-time adjuster denies the claim as personal sensitivity.
• The employee becomes very upset that the claim is not paid under workers' compensation even though he may have health benefits.  
• These claims have been litigated in certain states. 

Is it a better risk management technique to accept this claim and pay it rather than have a disgruntled claimant on your hands?

If the company that processes the claim is a third-party administrator, the employer should have a large say as to whether the claim is paid instead of creating a disgruntled employee situation. Remember, an adjuster who works in a TPA environment is spending the money out of a self-insured’s account. 

I remember having an agreement with certain self-insureds that personal sensitivity claims are to be paid and not denied. Some of those very small claims have turned into much worse claims that could not be denied later. 

This type of claim has been ruled on in many jurisdictions. I cannot make a blanket statement as to which states allow or do not allow these claims. 

This situation is one that should be run by the defense attorneys whom the adjuster usually works with on claims. Personal sensitivity claims may seem too insignificant to speak with a defense counsel. It will be well worth your time to know the answer even if you have not handled personal sensitivity claims.

I wanted to bring this issue to the attention of claims departments, safety managers risk managers and our other 7,000 weekly newsletter readers.

This blog post is provided by James Moore, AIC, MBA, ChFC, ARM, and is republished with permission from J&L Risk Management Consultants. Visit the full website at www.cutcompcosts.com.