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Flashcards in Claims Management - Deferred Claims Deck (35)
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1

New/deferred claims management

During the deferred status, the adjuster determines whether a claimed work injury or occupational disease can be covered under workers’ compensation insurance. There are tight timeframes and adjusters need to ensure decisions are made accurately and timely.

2

If the injury only requires first aid treatment, does a claim need to be filed?

No. First aid rendered at the job site is not considered medical services or treatment. Employers should document the incident. If the worker later seeks medical treatment or asks to submit a claim, the incident must be reported as work injury claim.

3

How many days does the worker have to report an injury to the employer?

- 90 days from the date of the injury or accident,
- the injured worker has up to one year to report the claim if he can show good cause for not reporting it sooner

4

How long does the worker have to report an occupational disease (OD) to the employer?

-One year from the date the worker first discovered the OD
-One year from the date the worker became disabled because of the OD
-One year from the date the worker is informed by a doctor of the OD
-One year from the date of death or when it was discovered the OD was the cause of death

5

How many days does the employer have to send the Form 801 to the insurer?

- five days from the date the employer is informed of the claim - EDOK

6

Legal standards for determining the compensability of a claim or condition? -- Initial Injury Claim
*What we base our decision on

Material Contributing cause of the need for treatment

7

Legal standards for determining the compensability of a claim or condition? -- OD claim
*What we base our decision on

Major contributing cause of the condition.

8

Legal standards for determining the compensability of a claim or condition? --Consequential condition
*What we base our decision on

compensable injury is the major contributing cause of the consequential condition

9

Legal standards for determining the compensability of a claim or condition? --Combined Condition
*What we base our decision on

major contributing cause of the combined condition’s need for treatment

10

Who has the burden of proof in the claim?

The injured worker has the burden of proof to show a claim is compensable.

11

What three situations typically make a claim NOT compensable?

- Injury occurs to any active participant in assaults or combats that are not connect to the job assignment and are a deviation for customary duties.
- Injury occurs 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.

12

How is an injury claim most often described?

An injury claim usually occurs within a discreet period of time. An injury has a sudden and acute onset.

13

How is an occupational disease (OD) most often described?

OD claims typically develop over a longer period of time.

14

What does the phrase “course and scope” mean when it comes to "arising out of"

means there is a causal relationship to work.

15

What does the phrase “course and scope” mean when it comes to "In the course of":

refers to the time, place, and circumstances surrounding the accident.

16

What four questions should you ask yourself to help determine if you are dealing with a compensable combined condition?

- Is there a compensable injury?
- Is there a qualified preexisting condition? (See the General Definitions section.)
-Did the injury combine with the qualified preexisting condition?
-Is the combined condition compensable?

17

In what situations could you revoke the notice of acceptance (also known as a back-up denial) once a claim has been accepted?

When the denial is for fraud, misrepresentation, or other illegal activity by the worker, or
The insurer later obtains evidence that the claim is not compensable or that the insurer or employer is not responsible (within two years after the date of the initial acceptance).

18

Who has the burden of proof when a back-up denial is issued?

The insurer.

19

Is everyone hurt in Oregon covered by Oregon Workers’ Compensation Insurance?

No. Not all employees hurt in Oregon work for an Oregon subject employer; and not all workers are Oregon subject workers (see definitions).

20

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.
and
-- Compensability is determined first, then responsibility: If the claim is compensable, is the employer responsible?

21

In context of a responsibility case, what is the Last Injurious Exposure Rule (LIER)

Used in occupational disease claims, the employer upon whom the rule “triggers” is presumptively responsible for the claim.

22

In context of a responsibility case, what is the Last Injury Rule (LIR)?

The last injury that made an independent contribution to the underlying pathology of the condition, even though it is slight, is responsible. A contribution to the symptoms, but not the pathology, is not sufficient.

23

What is the purpose of a designated paying agent order (also known as a .307 Order)?

The claim is compensable, but there is a dispute as to which insurer or employer is responsible. A designated paying agent order (.307 Order) allows the worker to receive benefits until the responsibility issue is resolved.

24

When is a designated paying agent requested?

It is requested when responsibility is the sole issue in the claim.

25

What is the role of SAIF’s Conflict Resolution Committee (CRC)?

The CRC’s role is to work with claims adjusters to determine if a responsibility conflict exists. If so, they advise the legal department of the need for outside counsel.

26

Under what circumstances must an insurer request suspension of benefits from WCD?

- Worker fails to attend an IME. OAR 436-060-0095(1)
- Worker commits insanitary or injurious acts. OAR 436-060-0105
- Worker fails or refuses to accept medical treatment. OAR 436-060-105
- Worker fails or refuses to cooperate with investigation. OAR 436-060-0135(2)

27

What is the timeframe within which the injured worker must cooperate with the investigation of the claim to avoid suspension of benefits?

14 days from written notice being sent

28

What information must be included on the acceptance?

- Compensable conditions,
-Disabling or nondisabling status,
- Information about the Expedited Claim Service, hearing, and aggravation rights related to nondisabling injuries,
- Employment reinstatement rights,
- Assistance available from the Reemployment Assistance Program,
- Reimbursement to the worker for out of pocket expenses for meals, lodging, transportation, and prescriptions,
- What to do if the worker believes a condition has been omitted,
- What to do if the worker wants the insurer to accept a new condition.

29

Who receives a copy of the acceptance?

- The worker,
-The employer (ORS),
- The worker’s attorney, if represented,
- The worker’s attending physician,
- The MCO, if enrolled,
- WCD (on disabling claims only).

30

What information must be included on the denial?

- The factual and legal reasons for the denial,
- The 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 the Expedited Claim Service,
- Appeal rights.