Important steps to take when investigating a claim

There are several claims management strategies to use when assessing a new claim that occurs in the workplace.

“It is important for employers to have a well-defined internal program in place so that you are prepared to deal with any injuries or incidents that may occur in your workplace,” says Debbie Smith, claims team lead at CompManagement. “The two most important are related to the investigation of a claim and the corresponding documentation. If a claim becomes contested, the steps an employer takes in the very beginning and the attention given to the details may assist them in defending against the claim if warranted.”

Smart Business spoke with Smith about what to look for, red flag indicators and recommended strategies for documenting a workers’ compensation incident.

What are the key factors in an investigation?

Take the time to review the circumstances surrounding the claim. Look at where the incident occurred and take steps to prevent another injury. Take pictures or review security tapes. Ask co-workers what they saw or know about the incident and about the injured worker, such as hobbies and outside activities. Conduct the investigation as soon as possible after an injury occurs so the details are fresh in everyone’s minds.

What are some red flag indicators?

Although the vast majority of claims filed are compensable claims, there are still some red flags that employers should be on the lookout for in order to prevent fraudulent claims from hitting their experience. Some important red flags include:

  • Lapse in injury reporting. A gap between the date of injury and the first notice to the employer could indicate that the injury occurred outside the workplace.
  • Timing of the injury. Was the injury reported prior to a holiday or before/after a weekend?
  • No witnesses. Lack of witnesses or accounts of the incident containing conflicting statements can lead to credibility issues.
  • Vague accident descriptions. Watch for those that do not paint a clear picture of what happened.
  • Work performance. Did the injury follow a disciplinary action? If so, the injury may be retaliatory in nature and lack objective evidence.

What questions should be asked?

Through the course of any investigation, there are five questions that should be asked that include:

  • What was the employee doing just before the injury occurred?
  • What happened?
  • What object or substance directly harmed the employee?
  • Were unsafe acts involved?
  • Were there unsafe conditions involved?

Why is documentation so important?

Any workplace incident should be documented whether or not it results in an injury or illness. The information will help clarify medical conditions related to the claim and can help an employer identify the need for training, additional safety equipment or procedural improvements. Make sure all reports are completed, such as an incident report, supervisor’s report, witness statements and Bureau of Workers’ Compensation paperwork. If a claim is contested, this information will be important to have available to defend against the claim.

What should be documented?

When developing your internal program, keep the following five items in mind:

  • Use the appropriate forms. Supervisors and any witnesses should document the incident, multiple witnesses should submit separate written accounts of the incident.
  • Make it mandatory. Communicate expectations with employees, managers and supervisors for documenting and reporting injuries.
  • Be thorough. The details of an injury are key factors in determining medical conditions that should or should not be included in a workers’ compensation claim.
  • Timing is important. The earlier the incident is reported and documented, the more valuable and accurate the information is from the involved parties.
  • Train your supervisors. All supervisors should understand that documentation should be timely and thorough.

 

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