How to Deal With a Workers Comp Claims Adjuster

If you’ve already filed a workers’ compensation claim, chances are you already have a workers’ comp adjuster working on your case. But if you think they’re there to help you get your benefits, then you’re absolutely wrong.

Most injured workers want to get their benefits as soon as possible. So if a workers’ comp claims adjuster comes knocking at their door claiming to collect information for their claim, they’ll just give them what they want thinking it will help speed up their claim. But that isn’t always the case.

Workers’ compensation adjusters work for the insurance company. Obviously, they will put the interests of that company over your welfare. Their main goal is to reduce your workers’ compensation amount or avoid paying it altogether. That’s why knowing how to effectively deal with them will help you get a favorable outcome.

What Does a Workers Comp Claims Adjuster Do?

Workers compensation claims adjusters are basically insurance adjusters that specialize in workers’ compensation cases. Their primary role is to weed out compensable from non-compensable workers compensation claims.  And if it’s compensable, how much benefits should be paid. They are trained, very skilled, and very knowledgeable about workers’ comp laws and processes.

In short, a claims adjuster’s job is to analyze workers’ compensation claims, review documentation, and determine the benefit due. This includes carrying out various tasks such as:

  • reviewing your workers’ comp insurance policy
  • confirm that you filed your claim within the time limit
  • gather medical reports related to your injury
  • interview witnesses to the accident
  • put together a team of doctors you can choose from
  • find out your average weekly wage before the incident
  • lookout for red flags they can use to deny your claim

Claims adjusters are also charged with negotiating settlements. And when a settlement is reached, they are then submitted to the claims administrator who ensures that the adjuster’s findings are accurate.

Common Claims Adjuster Tricks and Tactics

Since their job is to save their company some money at your expense, claims adjusters use various tricks and tactics to achieve that end. Most of them are legal but some may border on intimidation. Familiarizing yourself with these tactics will help you avoid falling prey to them.

1. Ask You to Sign Documents or Give Statements Immediately After the Accident

Insurance companies know that you’re at your most vulnerable in those few days immediately following the accident. So they typically send their workers’ comp adjusters to get a recorded statement or have you sign documents. Sometimes they do it while you’re still hooked to an IV. 

They do this because recorded statements often provide loopholes that they can use to deny your claim. 

2. Discourage You From Hiring an Attorney

Most insurance adjusters will tell you that hiring an attorney will only prolong your case. Or that after the lawyer takes his cut, you’ll be left with almost nothing. None of this is true.

In fact, those who hire workers’ compensation lawyers are more likely to get their claims approved. This is especially true for workers’ compensation cases that aren’t clearly work-related or need prolonged medical care. Also, lawyer fees take only a very small portion of your settlement amount. The rate is usually decided by the court but it can range from 15% to no more than 25%.

3. Delay the Process

If a claims adjuster knows that your finances aren’t looking good, they’ll typically delay the workers’ comp process. Delaying the process also delays your benefits. And if you’re in dire financial straits, you’ll usually just settle for whatever amount they’ll offer.

4. Don’t Answer Your Calls and Messages

Claims adjusters are very busy people. So it’s not uncommon for them to miss your calls or forget to answer your messages. But sometimes, they’ll deliberately ignore your phone calls or emails hoping that you’ll just give up your claim.

5. Calculate Benefits Incorrectly

Errors and miscalculations are unavoidable when you’re handling large volumes of workers’ compensation claims. But sometimes, claims adjusters deliberately miscalculate your benefits to reduce your payment amount. For instance, wage loss benefits can be up to 80% of your average weekly wage. In certain industries, the minimum wage rate and overtime pay can increase a worker’s average weekly wage. But some claims adjusters intentionally exclude such details in the computation thus understating your wage loss benefit.

A work injury claim form that has not been filled out yet.

6. Not Offering a Choice of Medical Providers

Workers comp laws require injured workers to get their treatment only from medical providers accredited by their insurance carriers. Otherwise, their claim can get denied. On the other hand, your insurance carrier should also provide you with a list of doctors you can choose from.

Some claims adjusters, however, will only refer you to one treating doctor without taking into account the nature of your medical condition. If you have a brain injury, for instance, and you are referred to a general medicine doctor, they might not be able to accurately diagnose the full extent of your injury.

7. Concealing Vital Benefits Information

Aside from medical benefits and lost wages compensation, your policy may also cover ongoing care costs and other related incidental expenses. But some claims adjusters will deliberately conceal that information from you to avoid paying such. And if you’re not that familiar with the legal jargon in your insurance contract, it can be very easy for them to get away with it. 

8. Stalk You on Social Media

This is one of the most common tactics used by claims adjusters. They’ll add you or your immediate family and friends on social media to spy on you. Then they’ll look for any posts or pictures that they can use to disprove your claim. Sometimes they’ll create a fake account to befriend you until you tell them things that might jeopardize your claim. So if you’re in the process of filing a claim, be careful of strangers sliding into your DMs and sending you friend requests.

9. Forcing You to Sign a Blank Medical Authorization 

Insurance carriers need a signed medical authorization to access your medical records and check for any pre-existing diseases. But it’s not unheard of for claims adjusters to force an injured worker to sign a blank medical authorization. This gives them free rein to unearth medical records even those from decades ago. If they can find a link to your current medical condition from an illness you had in the past, they can use it as evidence of a pre-existing illness (even though the two are totally unrelated).

So for your peace of mind, never sign a blank medical authorization. And if you do sign an authorization, make sure that it has clearly set limitations on what records they can only look into.

10. Delay Wage Loss Payments

Wage loss payments are supposed to arrive every week without fail. Though the process is automated, it still requires input from the claims adjuster. Unfortunately, some of them would deliberately delay your wage loss check so you’ll be forced to either settle or go back to work prematurely. Either way, your benefit payments will stop.

11. Not Authorize Medical Treatments 

Though you are entitled to medical benefits, all medical treatments should still be authorized by insurance companies before they can be administered. But it’s quite common for insurance companies to deny medical treatments prescribed by doctors. This will not only delay your recovery but can also worsen your condition. If your claims adjuster refuses to authorize medical treatment, make sure to tell your attorney about it.

12. Send You to an IME

When the insurance company disagrees with your treating doctor’s diagnosis, they can send you to an independent medical examiner (IME). Their diagnosis usually becomes the basis of the court’s decision on whether to approve or deny your claim.

Don’t be fooled by the name though. Independent medical examiners are (most of the time) not independent. They are under the insurance company’s payroll. As such, you can’t expect them to look out for your best interests.

If your insurance provider is sending you to an IME, make sure to talk to a workers’ compensation lawyer first.

13. Sending a Private Investigator After You

This might sound a little extreme but it does happen. Sometimes, the claims adjuster will do the spying themselves. But if they are flooded with work, they may hire a workers comp investigator to tail after you. The investigator has one job: gather evidence to disprove your claim. If you think you’re being followed by one, make sure to talk to your lawyer and don’t give out any information that they can use against you.

Tips When Dealing With a Workers Comp Claims Adjuster

Since claims adjusters have a lot of tricks up their sleeves that dealing with them can be a headache. So we’ve compiled these do’s and don’ts when dealing with workers comp claims adjusters:

1. Report Your Claim ASAP

In most states, you only have 30 days to report work-related accidents to your insurance provider. Failing to file a claim within this time frame will give the adjuster reason to deny your claim.

2. Return Calls Promptly

Claims adjusters handle hundreds of workers comp cases at any given time. So they ten to make hundreds of calls every single day. If they called you and you don’t answer or return their calls, chances are they won’t be calling you again for the next few days. This could delay your claims process further.

3. Find Out How Many Caseloads They Have

When a claims adjuster handles too many cases at once, they’re unlikely to bother with minute details. So you have better chances of getting your claims approved. That’s why finding out how many caseloads your adjuster currently has is very important. It can help you gauge the level of scrutiny you’ll receive from them.

4. Don’t Submit an Incomplete Injury Form

One thing that claims adjusters hate the most is an incomplete injury form. It adds up to their work and requires them to make multiple calls. And an irritated workers comp claims adjuster is never good news. So always make sure to completely fill in your workers’ comp injury form before turning it in.

Besides, if you leave some portions blank, other people may fill it up and you may not like what they’ll put on it.

5. Don’t Just Give Out Recorded Statement

As mentioned, it’s not above claims adjusters to force out a recorded statement from you even while you’re still lying in the hospital bed. But know that you are not required to nor should you give out a recorded statement. Remember that the information you reveal in that statement can be used against you. Politely tell them to wait until you’ve gotten your bearings and are in a proper state of mind to give out a statement.

6. Don’t Sign a Medical Authorization Form

AS mentioned, medical authorization forms allow claims adjusters access to your medical records. But you don’t have to sign this form and they can’t force you to. Remember that they can use your medical records and any pre-existing condition to deny your claim or reduce your benefits.

7. Don’t Settle Unless You’ve Consulted an Attorney

One common mistake injured workers make is to settle without consulting an attorney. Remember that insurance companies don’t have your best interest at heart. So the amount they’re offering you is probably much lesser than what you are entitled to.

If you feel like you’re getting the short end of the stick, don’t hesitate to call an experienced lawyer like Victor Malca. He has already helped thousands of injured workers in Florida get the benefits they rightfully deserve. He can help you too. Call us now for a free consultation.

VICTOR MALCA LAW – A TRUSTED NAME IN FLORIDA

Victor Malca P.A. has over 25 years of litigation experience in Workers Compensation and Social Security Disability lawsuits. His experience and continued success in fighting for his clients puts among the most trusted workers’ compensation lawyers in Florida. Our area of expertise is in representing injured workers on compensation benefit cases and disabled individuals claim social security disability benefits.

Our unwavering advocacy for employee rights and privileges are recognized by our past clients across South Florida. Book a free consultation today.

Judy Ponio is a writer for Victor Malca LawAbout The Author

Judy Ponio is a writer for Victor Malca Law P.A. and enjoys helping people with questions about social security, workers compensation, and other serious matters involving people’s livelihood. She is not an attorney and her writing should not be considered legal advice.

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