Why do injured workers turn to attorneys in workers’ compensation cases?

Workers’ compensation is a complicated and litigious market. Many of the headlines we see revolve around settlements paid out in court. Some believe litigation is the consequence of injured workers who collaborate with attorneys to take advantage of the system, but data paints a different picture. 

4 system failures that lead to litigation

Adjusters are overloaded - Most experts agree a single adjuster should manage no more than 120 cases simultaneously, but according to a 2016 Claims Salary Survey many manage over 150 cases. And not all claims (or adjusters) are created equal. Lost-wage claims take longer to process and require more effort than medical-only claims. However, many claim management organizations do not factor the varying degrees of complexity or time engagement when adjusting caseloads.

Adjusters don’t have time to contact injured workers - While communication between the worker, employer and insurer might seem like an essential aspect of claims management, the reality is different. According to 2015 audit on claims management organization conducted by Washington State, only 15% of adjusters communicated with injured workers and employers within 30 days from receiving a claim.

Injured workers are dissatisfied with service - Not surprisingly, the lack of basic service due to overburdened adjusters results in extremely unhappy customers. Overall, 14% of injured workers report being “very dissatisfied” with workers’ compensation services, and 17% report “big problems” getting access to medical services on average across 15 states, according to an Insurance Information Institute analysis.

Worker’s compensation is very hard to navigate - Workers’ compensation relies on, and adds complexity to the U.S. health care system, which is already one of the most complicated and inefficient in the industrialized world, says the Organization for Economic Co-operation and Development. In turn, most employers rely on their insurance or third-party administrators and are hesitant to communicate directly with employees for fear of litigation.

A breakdown in communication

Unhappy and ill-advised employees could take advantage of this complex situation, but they may not be the majority. A severe breakdown in communication can also explain litigation.

Consider the following example. John Smith is an imaginary worker who sustained a minor injury on the job. Advised by his supervisor, he attends the emergency room where he checks in with his health insurance card, receives treatment and is prescribed rest for five days. In the meantime, the supervisor reports the incident to the employer’s insurance, who in turn notifies the third-party administrator.

The case is now assigned to an overloaded adjuster who is unable to review the file or contact John. A month later, the hospital sends John a large invoice because his personal health insurance is unwilling to pay for work-related accidentsJohn contacts his supervisor and asks for reimbursement and lost wages, but the supervisor has no answers because she is also unable to communicate with the adjuster. John also receives a letter describing his rights for workers’ compensation written in “legalese,” a complex language he does not understand. With nowhere else to go, John contacts an attorney who promises a large settlement. The employer responds, but the relationship is already damaged, and John’s future with his current employer is uncertain.

Though oversimplified, this example describes a common reality that can easily be avoided with better care coordination and injured worker advocacy, two modern trends that could bring workers’ compensation costs closer to group health levels.

Posted 9:00 AM

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