What Does A Worker’s Compensation Claim Adjuster Do?

The main task of a worker’s compensation claim adjuster is to make a determination regarding the claim by receiving and organizing all necessary documents associated with the employee and the injuries suffered by him or her. If you have got injured while on job, you have the legal right to ask for monetary compensation from the employer, which is basically provided to cover the medical expenses thus caused. However, in extreme cases, where the injuries result in temporary or permanent disability, the compensation amount may also include a part of the regular monthly salary to cover the other monthly expenses of the employee’s household. There is a set procedure that a person has to follow in order to file a worker’s compensation claim. When it comes to making claim determination, the adjuster must abide by the company guidelines. However, it is very important for you to keep in mind that the duties of the adjusters and the guidelines that they follow may vary significantly from one company to another. Following is a brief rundown on some of the basic things that you must know in this regard.

Pre-Claim Duties

The role of the worker’s compensation claim adjuster starts when an authority from the human resource department of the company informs him or her about the incident. When an employee gets injured in an on-the-job incident, the first thing that the employee must do is to seek immediate medical attention. The employee must visit a health care facility or a doctor’s clinic and get proper treatment. The early diagnosis of the injuries is very important. These medical reports become a legal proof that the injuries occurred and that the injuries were caused by factors for which the employer can be held responsible. Some cases can be very complicated, such as the ones where the injuries or the medical problems caused at workplace are not noticed initially. For example, there can be a situation where people work in hazardous conditions, such as in a factory where poisonous gas is emitted in a very small quantity, which gradually affects the health of the workers. In such cases, the problem is noticed at a later stage. No matter whether the case is a simple or a complicated one, the initial task of the adjuster is to contact the injured employee and ask him or her to provide the details of the events surrounding the injuries, such as the place where the injury occurred, how it happened, the severity of the injuries, and other such things. The adjuster then also contacts the doctor or the health care provider (who did the early diagnosis) to obtain medical reports from them.

Determination Of The Claim

Once the worker’s compensation claim adjuster collects all basic information (such as the medical reports, the statement of the employee, and appropriate forms from the employer), they perform a thorough assessment with an objective to determine whether the injuries are work-related or not. If the adjuster determines that the injuries are not work-related or that the injuries are not caused by factors for which the employer can be held responsible, the worker’s compensation claim is denied. However, even at this point, the injured employee has the legal right to file an appeal. On the other hand, if the adjuster determines that the injuries are work-related and that the injured employee must be compensated, the claim is filed for further proceedings.

Opening And Closing A Claim File

A worker’s compensation claim adjuster has to perform an array of tasks regarding the opening and closing of a claim file. A claim file is opened when it is determined that the injuries are work-related and that the claim meets all additional legal criteria as defined by the state and federal laws for worker’s compensation. In most cases, the employee has to file medical claims several times. Every time a medical claim is filed, the adjuster receives the claim, does a thorough evaluation, and forwards the file to the concerned department for payment. It is also the responsibility of the adjuster to be in touch with both the injured employee as well as the doctor who is treating the patient in order to remain updated with the status of the injuries and further treatment plans. When the adjuster determines that the employee does not need any further treatment, they close the file, which means no further claim can be made by the employee.

Overall, as you can see, a worker’s compensation claim adjuster has to play a very important role. The adjuster has to ensure that the rights and interests of both the employees as well as the employers remain protected.