The News You Need for Jan. 7
What to do to support the claims experience. How to make early interventions work. A look at Pennsylvania compliance. And a Florida case about a teacher's headaches.
Supporting a Positive Claims Experience: Enhancing Trust and Recovery?
Roadmap
The claims process is pivotal for injured workers, shaping their perceptions of their employer and the workers' compensation system. A positive claims experience ensures injured employees feel supported, respected, and empowered during challenging times. Employers play a critical role in fostering this experience by focusing on clear communication, empathy, and efficient claims handling. In this article, we show how to create a claims process that minimizes stress and maximizes trust, providing a foundation for successful recovery and return to work.?
Step 1: Foster Open and Transparent Communication?
What to Do:?
Maintain clear and consistent communication with the injured worker throughout the claims process.?
Why It Matters:?
Transparency builds trust, alleviates confusion, and empowers the injured worker to navigate the process confidently.?
How to Do It:?
Step 2: Show Empathy and Understanding?
What to Do:?
Approach every interaction with compassion and empathy, acknowledging the physical and emotional challenges the worker is facing.?
Why It Matters:?
Empathy fosters a sense of care and respect, making the injured worker feel valued and supported.?
How to Do It:?
Step 3: Minimize Administrative Hurdles?
What to Do:?
Streamline the claims process to reduce unnecessary delays and paperwork that can frustrate injured workers.?
Why It Matters:?
Simplifying administrative tasks ensures injured workers can focus on their recovery instead of navigating a cumbersome process.?
How to Do It:?
Step 4: Collaborate with Key Stakeholders?
What to Do:?
Coordinate with adjusters, medical providers, and supervisors to create a seamless and supportive claims experience.?
?The claims adjuster, in particular, plays a crucial role in assessing the claim's validity, coordinating medical treatment, and managing the financial aspects of the claim. Effective collaboration with the adjuster can significantly improve the overall claims experience for the injured worker.?
Why It Matters:?
Collaboration aligns all parties in prioritizing the injured worker's well-being and recovery.?
How to Do It:?
Step 5: Provide Resources and Guidance?
What to Do:?
Equip injured workers with the tools and information to navigate the claims process effectively.?
Why It Matters:?
Access to resources reduces confusion and empowers workers to participate actively in their recovery.?
How to Do It:?
Step 6: Address Concerns and Feedback Proactively?
What to Do:?
Encourage injured workers to share feedback about their claims experience and promptly respond to concerns.?
Why It Matters:?
Listening to feedback helps identify areas for improvement and shows the worker that their input is valued.?
How to Do It:?
Step 7: Emphasize Timeliness in Claims Handling?
What to Do:?
Prioritize efficiency in processing claims to minimize delays in treatment and benefits.?
Why It Matters:?
Timely claims handling ensures that workers receive the care they need promptly, fostering trust and improving outcomes.?
How to Do It:?
Step 8: Celebrate Successes and Milestones?
What to Do:?
Recognize and celebrate the injured worker's progress throughout their recovery journey. This recognition could be as simple as acknowledging their efforts, giving them a small gift to mark a milestone, or holding a team celebration when they return to work.?
Why It Matters:?
Acknowledging milestones boosts morale and motivates workers to stay engaged in their recovery.?
How to Do It:?
Fostering a Culture of Support Through Claims Management?
A positive claims experience reflects an organization's broader commitment to employee well-being. By prioritizing empathy, transparency, and efficiency, employers can create a workers' compensation process that respects the dignity and humanity of injured workers. In our following article,?Understanding Temporary Disability Benefits, we will explore the role of these benefits in supporting injured workers financially and emotionally during their recovery. Join us as we continue to build a roadmap for success that benefits everyone involved.?
Early Intervention, Lasting Solutions: A Modern Approach to Reducing Injury Severity?
In the complex world of workers’ compensation, early intervention has emerged as a pivotal strategy for minimizing injury severity, reducing claim costs, and improving worker outcomes. By addressing injuries promptly with a holistic approach, insurers can not only enhance recovery outcomes but also strengthen relationships with employers and injured workers. At its core, early intervention is more than a claims management tool—it is a transformational approach that aligns financial sustainability with compassionate care delivery.?
The Case for Early Intervention?
Delays in medical treatment and claims processing have long been recognized as significant contributors to prolonged recoveries, increased costs, and worker dissatisfaction. Early intervention programs directly address these challenges by prioritizing immediate action and coordinated care.?
Faster Recovery?
Timely medical attention is critical in the recovery process. Early intervention reduces the risk of complications such as secondary injuries, delayed healing, or psychological distress. Prompt triage ensures injured workers receive appropriate care at the right time, accelerating their return to work and reducing overall claim duration.?
Lower Costs?
The financial impact of delayed treatment is profound. Prolonged claims often escalate in medical expenses, indemnity payments, and administrative overhead. Early intervention mitigates these risks by facilitating earlier diagnoses, preventing unnecessary treatments, and managing care efficiently. Studies consistently show that early engagement leads to significantly lower total claim costs.?
Improved Satisfaction?
Workers who feel supported and valued during the claims process are more likely to trust their employer and the insurance carrier. Early intervention fosters a sense of security and confidence by providing immediate guidance, access to care, and ongoing support. This enhances morale but also reduces the likelihood of disputes or litigation.?
Implications for the Workers’ Compensation Industry?
Implementing early intervention programs is not without its challenges. It requires a coordinated effort among insurers, employers, and healthcare providers, as well as investments in technology, training, and process optimization.?
Collaboration Across Stakeholders?
Effective early intervention depends on seamless communication and collaboration. Insurers must work closely with employers to establish protocols for injury reporting and triage. Healthcare providers play a critical role by delivering prompt and appropriate care, while case managers ensure continuity and alignment of treatment plans.?
Leveraging Technology?
Modern technology is a cornerstone of early intervention. Tools such as predictive analytics can identify claims that are likely to escalate in severity, enabling proactive engagement. Additionally, 24/7 nurse triage lines and digital reporting platforms facilitate immediate response and streamline communication between all parties.?
Education and Training?
The success of early intervention programs hinges on the awareness and preparedness of all stakeholders. Employers and supervisors must be trained to recognize and report injuries promptly, while insurers and case managers need to be equipped with the skills and knowledge to guide injured workers through the process.?
Strategic Recommendations?
To unlock the full potential of early intervention, insurers must adopt a comprehensive and strategic approach. The following recommendations highlight key initiatives to consider:?
24/7 Nurse Triage Lines?
Providing injured workers access to medical professionals around the clock is a fundamental component of early intervention. Nurse triage lines offer immediate advice and direction, ensuring that workers receive appropriate care while avoiding unnecessary emergency room visits. This not only expedites treatment but also reduces medical costs and anxiety for injured workers.?
Predictive Analytics?
Harnessing the power of data analytics is essential for identifying high-risk claims early in the process. Predictive models can flag cases that are likely to benefit from intervention based on factors such as injury type, worker demographics, and historical claim data. By focusing resources on these cases, insurers can mitigate potential complications and improve outcomes.?
Case Management?
Dedicated case managers serve as a central point of contact for injured workers, employers, and healthcare providers. Their role is to coordinate care, facilitate communication, and ensure that treatment plans are aligned with recovery goals. A personalized approach not only enhances the efficiency of the claims process but also fosters trust and satisfaction among all parties.?
The Competitive Advantage of Early Intervention?
In an increasingly competitive and complex workers’ compensation landscape, early intervention represents a clear pathway to success. Insurers who prioritize proactive and holistic claims management are better positioned to achieve superior outcomes, both financially and operationally.?
Early intervention is not just about reducing costs—it is about redefining the claims experience. By addressing injuries promptly, coordinating care effectively, and leveraging innovative tools, insurers can create lasting value for injured workers and their employers. Moreover, the emphasis on timely and compassionate care strengthens relationships, builds loyalty, and enhances the overall reputation of the organization.?
The time for early intervention is now. Insurers who embrace this approach will not only drive better results but also set a new standard for excellence in workers’ compensation.?
What is Pennsylvania’s ‘Personal Animus’ Exception???
Chris Parker
Do You Know The Rule?
The general rule in Pennsylvania is that an employee cannot sue his employer for personal injury arising from his employment.?
Pennsylvania’s “personal animus” exception makes it possible to sue for personal injury under certain circumstances. Per the exception, an employee’s injury in the workplace is not compensable under the WCA if it is the result of someone else’s personal hostility toward the employee.??
The exception sometimes comes up in cases where an employee is murdered and the employee’s spouse or estate seeks death benefits under the WCA. It’s more likely arise, however, with respect to assaults at work that end in injury but not death. The workers’ compensation carrier might defend itself against the claim by arguing that the attack was merely a personal dispute between the two employees, or personal hostility on the part of the attacker.??
General Rules?
The exception applies if:?
Thus, if the employee was merely an innocent victim of the attack, the above requirements are not met. In that case, the attack generally would be considered an unexpected happening that arose in the course of employment and that is covered by the WCA.?
Source of the Exception?
The exception arises from the WCA’s definition of injury arising in the course of employment, which states that the term does not include an injury caused by an act of a third person intended to injure the worker because of reasons personal to him and not directed against him as an employee or because of his employment.?
Burden to Establish that the Exception Applies?
Courts assume an injury is work-related if it occurred while the employee was working. The party seeking to establish that the exception applies has the burden of including facts in their pleadings showing that the attack was motivated by personal animosity unrelated to employment.?
Note that the party arguing that the exception applies may be the employer, carrier, or employee. The employee, for example, may want to establish the exception to overcome the general rule that the WCA is his sole remedy for work-related injuries. If he can show the WCA does not apply, he’s free to bring a negligence or other tort lawsuit against the employer—a potentially far more expensive proposition for the employer.?
Potential Evidence?
When asserting the exception, it’s important to look for any indications of hostility on the part of the attacker that pre-existed the incident. Parties claiming the exception applies may need to seek statements from coworkers of the two employees, especially those who witnessed the incident or were familiar with how the two got along at work. A police report and any law enforcement records addressing intent are likely to prove helpful, as are statements from the spouses of both individuals.?
Case Examples?
Grabowski v. Carelink Cmty. Support Servs., 230 A.3d 465 (Pa. 2020) (holding that the personal animus exception didn’t apply where the employee, who was attacked by a resident of the employer’s facility, failed to allege any motivation for the attack in the pleadings).?
Scantlin v. Ulrich,?465 A.2d 19 (Pa. Super. 1983)?(holding that the employee failed to establish the personal animus exception applied where he asserted an intentional injury caused by his co-worker but did not state that the co-worker's action was driven by personal animosity toward the employee).?
Fla. 120-Day Rule Operates to Make Teacher’s Claims Compensable
Case File
When a Florida teacher sought continuing medical treatments for headaches she experienced after being hit by a student, her employer's failure to contest the compensability of those headaches within 120 days meant she won the compensability battle. Simply Research subscribers have access to the full text of the decision.
Case
Silvia-Pabalan v. Pinellas County School Board, No. 23-005542JPM (Fla. OJCC)
What Happened
A middle school teacher took an upset student outside the door of her classroom, and while she was speaking with this student, one of the student's classmates came from behind the teacher, "pushed through her," and hit the student. The teacher testified that her neck and shoulder were hit and that she didn't remember if she was hit in the head during the incident.
Following treatment over the course of several months, the teacher reported that her shoulder problems had resolved, her neck problems had improved, and that she continued to have problems with headaches, dizziness, confusion, balance, and nausea.
The teacher sought authorization for medically reasonable and necessary treatment with a neurological specialist for the injuries after the initially authorized neurologist declined to provide further care.
Rule of Law
Under Florida Statuate Section 440.20(4), “A carrier that fails to deny compensability within 120 days after the initial provision of benefits or payment of compensation as required under subsection (2) or s. 440.192(8) waives the right to deny compensability, unless the carrier can establish material facts relevant to the issue of compensability that it could not have discovered through reasonable investigation within the 120-day period.”
In applying the 120-day rule, the relevant inquiry is whether the employer or carrier denied compensability within 120 days of first providing treatment.
After 120 days pass following the initial provision of benefits for a specific injury or condition, the injury or condition is deemed compensable by operation of law, unless the employer or carrier can establish material facts relevant to the issue of compensability that it could not have discovered through reasonable investigation within the 120-day period. Once compensable by operation of law, the burden shifts to the employer or carrier to show a break in the causation chain so that the compensable injury or condition is no longer the major contributing cause of the need for treatment.?
A break occurs when the work-related cause drops to 50% or less of the total cause of the need for the requested benefit.
Workers' Comp 101: Under Sierra v. Metro Protective Services, 188 So.3d 863 (Fla. Dist. Ct. App. 2015), an analysis of Florida's 120-day rule requires three findings: 1) the date the employer or carrier first provided benefits for the claimant's condition; 2) the identity of the specific injury for which benefits were provided; and 3) whether the employer or carrier timely denied compensability of the injury for which it provided benefits.
What the OJCC Said
Because the first recorded notation in the medical records that the teacher complained of headaches was on Jan. 27, 2023, and the first denial of the teacher's headaches was May 6, 2024, the denial was "made well after 120 days after medical care for the [teacher's] headaches was provided," the OJCC wrote.
Additionally, the employer and carrier did not prove or even allege a break in the chain of causation, and thus the teacher established compensability of her headaches.
Takeaway
For an employer to escape operation of Florida's 120-day rule, it must show that it denied compensability within 120 days of first providing treatment. Otherwise, the injury becomes compensable by operation of law.