Flashcards in Claims Management Deck (60)
What two questions should adjusters ask themselves every time they review an open claim?
What do I need to do to bring this claim to resolution?
Are my reserves adequate?
How many DAYS does the insurer have to reclassify a claim from NONDISABLING to DISABLING
14 days from
-receipt of information that the claim is disabling
-request from IW to reclassify the claim
-if its MORE than ONE year from the date of acceptance, the IW must file an AGGRAVATION claim
When a worker is represented by an attorney, when do you need to provide discoverable documents?
14 days from the request from the attorney
For an attorneys request, How often and for how long do you need to provide updates ?
every 30 days for 180 days
Why is it important to set reserves on a claim?
-Enables SAIF to ESTIMATE FUTURE LIABILITIES
-Reserves are used in RATEMAKING and CALCULATION of the employer's MODIFICATION RATE
-used to CALCULATE PREMIUM for RETROSPECTIVE POLICIES
- FACILITATE UNDERWRITING DECISIONS
- meets STATUTORY REQUIREMENTS
In what four areas is a claims adjuster responsible for setting reserves?
-TD : Temporary Disability
-PPD : Permanent Partial Disability
-Legal Cost (fees)
When is an adjuster required to set reserves on a claim?
-Within 30 days of receipt of the request for hearing on a denied claim condition
-Within 30 days of ACCEPTANCE of a DISABLING CLAIM
-On accepted, nondisabling claims, when cost exceed $5,000
These examples should prompt you to do what action?
-change in the TL authorization
-change in Work release or Work Status
-receipt of medical information such as surgery
-claim closure information
-request to reopen a claim
-request to accept new, omitted, consequential, or combined conditions
-Passage of time W/O further TX or activity in the claim
Review the reserves on a claim
How many days does the worker have to report an injury to the employer?
90 days from DOI or accident up to 1 yr with good cause.
worker has 90 days from Date of health benefit rejects a claim as being work related.
In most instances, who has the burden of proof in the claim?
IW has burden of proof to show a claim is compensable
What are the instances when a claim would most likely NOT be compensable?
-to an active participant in ASSAULTS OR COMBATS not connected to the job assignment and are a deviation for customary duties
-while engaging in or performing any social or recreational activity primarily for the WORKER'S PLEASURE
- Major contributing cause of the injury is caused by the worker's consumption of DRUGS OR ALCOHOL. Major cause must be demonstrated by a preponderance of the medical evidence
What are the legal standards for determining compensability in an injury claim ?
material contributing cause of the need for treatment or disability
How much time does the employer have to send Form 801 to the insurer?
5 days from the date of the employers knowledge that a claim is being made
compensable injury is the major contributing cause of the ...
What are the legal standards for determining compensability in an occupational disease claim?
MAJOR CONTRIBUTING CAUSE of the CONDITION
_____ _____: is the major contributing cause of the combined condition's need for treatment
What does the phrase "COURSE AND SCOPE" mean?
"arising out of"---causal relationship to work
" in the course of"--- time, place, and circumstances
Is everyone hurt in Oregon covered by Oregon Worker's Compensation Insurance?
No, not all employees hurt in Oregon work for and Oregon Subject employer; and not all workers are Oregon Subject workers. ORS 656.027
In addition to overall compensability, What other issue must an adjuster consider before making a decision on the claim?
RESPONSIBILITY: only one employer can be responsible for the compensable injury or OD.
Compensability is determined first, then responsibility: if the claim is compensable, is the employer responsible?
under what circumstances must an insurer request suspension of benefits from WCD?
-fails to attend an IME OAR436-060-0095(1)
-Worker Commits insanitary or injurious act OAR 436-060-105
-Worker fails or refuses to cooperate with investigation OAR 436-060-0135 (2)
Where can you find information on what is included for notice of acceptance
ORS 656.262 (6)(b),
What information must be included on the denial?
-Factual and legal reasons for denial
-worker's right to request a Worker Requested Medical Exam (WRME)
-Whether the denial was based in whole or in part on an independent medical exam (IME)
-Whether the attending physician agreed with the IME
-Information about Expedited Claim Service
How many days does a worker have to appeal a denial?
60 days from mailing date of denial
When should an adjuster make a referral for a RTW consultant?
-When the IW begins to miss time from work
-When there is an expectation that the worker will soon BEGIN to miss time from work
What are the elements of a formal job offer (BONA Fide Job offer)
-AP is notified of physical task to be performed
-AP agrees with proposed work MOD and commute is within IW physical capabilities
-Employer provides a written offer to IW
What information must be written in a Bona Fide Job offer?
-START DATE and TIME
-DURATION of the MOD work
-APPROVAL STATEMENT from AP
-Description of PHYSICAL REQUIREMENTS
-PLACE and LOCATION of MOD work
-HRS and DAYS to be worked
-WAGES for Mod work
What elements are needed to stop or prorate time-loss benefits when a worker has been terminated?
(what are the requirements)
-the employer has a RETURN-TO-WORK POLICY
- the AP has APPROVED mod job descriptions
What must be included in the Memo needed to stop or prorate time-loss benefits when a worker has been terminated?
-HRS and DAYS modified work would be available
-WAGES for Mod work
-START DATE and TIME
-STATEMENT that modified work WOULD HAVE BEEN available if the worker had not been terminated
In what situation can a worker refuse modified work without facing a reduction or termination of time-loss benefits?
-COMMUTE is BEYOND the physical Capacities for IW
-WORKSITE is MORE THAN 50 Miles from worksite-at-injury or IW's RESIDENCE
-Mod work is NOT WITH EMPLOYER AT INJURY
-Mod work is at a DIFFERENT SHIFT that the IW usually works