To help our clients avoid problems rather than try to repair any damage later on down the road, Margaret, a former adjuster, shares the issues that are “red flags” from an adjuster’s point of view.
Red Flags Adjusters Look for in Workers Comp Claims
Late Reporting –
When does the injured worker claim the incident happened and when was the injury formally reported to the employer, health services, or insurance company? The more time that passes, the bigger the red flag.
An automatic red flag is raised when a worker claims to have been injured on a Friday but doesn’t report it until Monday. It raises the question, were you genuinely injured on Friday at work or did it happen over the weekend. So, if you injure yourself on Friday, report it on Friday to avoid any doubt, even if the only way to reach your employer is through text or email.
Also, did you need medical treatment immediately or did you wait? The longer you wait, the more doubt about the severity of your injury and if it actually did happen at work.
Bottom line – report it right away, even if you don’t think you need medical care at that time.
If anyone is around who can verify the location, time, and how or why the injury occurred, get names and phone numbers. For example, were you lifting and did you complain or appear hurt? If you have witnesses, make sure they saw and know what happened to corroborate your claim when contacted.
Another big red flag is if your complaint sounds intentionally exaggerated. What happens if x-rays or an MRI show no visible injuries and you claim that your whole back, arm, or body hurts?
Doctors and adjusters will look for prior claims and injuries to the same body part, which isn’t a big deal on its own. However, if the client denies ever having a previous injury, that raises a red flag.
Always disclose any issues or problems from the past because when the truth comes out, your honesty will be in question, which could jeopardize your claim.
Recorded statements –
You’ll need to give an accurate history of the incident. An adjuster will look if your statements to the employer, doctor, and insurance company are consistent. If there are differences among those accounts, that’s a major red flag.
Complying with medical treatment –
If you are missing medical appointments or treatments, it may appear that your injury isn’t as severe as you claim. If this is the case, your temporary benefits could be cut off, especially if you are not working and getting paid lost wages.
Keep the lines of communication open with your employer.
If you have medical restrictions, but your employer can accommodate those restrictions, then try it out to see if you can do the job.