Hello There, Guest! Login Register
Index    |     Search    |     Members    |     Help

Thread Rating:
  • 2 Vote(s) - 5 Average
  • 1
  • 2
  • 3
  • 4
  • 5
Comments from a claims adjuster - Long
#31
(12-11-2010, 12:10 AM)GKelly Wrote: Greetings all.  

I am a workers' compensation claims adjuster in Louisiana.  I've been doing this for about eleven years.  I sometimes refer to the workerscompensation.com section relating to the laws and statutes.  I had never looked at the forum but the other day I decided to check it out, just out of curiosity.

I have to say, I am completely in shock at so many of your experiences with your adjusters!  I work for a company that apparently is not the norm.  It's a small office; five adjusters and a Manager.  Our Manager has always instilled in us to do the right thing by the injured worker; both legally AND morally and by nature, all of the adjusters welcome the 'authorization' to do that.  

In all of my eleven years and hundreds of claims that I've handled, it is very rare that I out and out deny a recommended course of treatment. Example:  One of those denials was a request for Viagra for a fractured index finger.  Due to the fact that the injured worker was not on any injury-related medication that would interfere with that 'ability' and the injury itself was not the cause of that 'condition';  well, it just didn't fit the 'reasonable and necessary' definition and, his physician, chosen by him, couldn't relate it.  The injured worker had a great sense of humor and understood why I couldn't authorize it.  But, that's my point.  I've only denied those things that in no way, shape or form were related to the injury or through indisputable evidence it was learned that the injury was not work related and could not be covered under workers' comp.  There have been several times that I've had the displeasure of learning, through a phone call from a relative, that the individual was faking an injury, was collecting wage-replacement (indemnity) benefits and was either working with friends for cash or had gone to work someplace else (even though their doctor said they were TTD).  And, even in those cases, I didn't terminate benefits until I gave them and their attorney  the evidence that proved the fraud and gave them numerous opportunties to voluntarily dismiss the claim so I wouldn't have to drag them (both the injured worker AND the attorney because the attorneys  knew each one was a fradulent case) before the Court or press formal charges.  Unfortunately, there ARE some that will be dishonest to some degree and that's just reality.  Those few dishonest ones are irritating to me because they take valuable time away from me; time  that needs to be spent on those legitimate claims in order  to keep them running smoothly with as little inconvenience and disruption to the injured worker's life as possible, under the circumstances.  

Unfortunately, a few bad apples can cause an adjuster to become jaded and suspicious of each and every claimed injury. I however, am not one of those adjusters.  I've had  many injured workers tell me that I was nothing like the horror stories they had heard about workers comp adjusters. After reading these posts, I see what they were referring to.

Those adjusters that are putting some of you through h**l, give fair, decent, compassionate adjusters like me a bad name and I am so disappointed that you all are being treated so unfairly by a system that was designed to help you when you had a work-related injury.

As an adjuster who works very hard on your behalf, it hurts to read on here that the majority of you despise 'me' and feel like I am walking evil.  I assure you, not all of us are bad.  Some of us truly do care and will go above and beyond to make sure that you are taken care of and receive the treatment you need and/or want so that you can return to your pre-injury condition or as close to that as possible.  

And, as far as settlements go, for those claims that settlement is appropriate, not all adjusters will try to short-change you.  Where I work,  my Manager would kick us to the door if we even tried to give you less than what your claim is worth (fortunately, no one in OUR office wants to give you less).  I had claim several years ago that was ready for settlement.  The injured workers' attorney provided me with his evaluation and the number that his client would settle for - $80,000.00. I did my own evaluation; his client's claim was actually valued at $318,000.00. Only about $25,000.00 of that was medical as he only got one medication and saw the doctor once a year.  Can you guess what I settled for?  Yep - $318,000.00.  Although his attorney wanted this all up front, (bigger fee) I didn't do that.  Not because I'm mean. You see, this individual was an older gentleman who had dropped out of school in the 7th grade and did not have the capacity to effectively manage such a large sum of money. This money had to last him for the rest of his life because he couldn't work anymore.  If he would have been given it all, he would probably have been broke within a year because I'm pretty sure he would have been generous to the people around him.  I convinced his attorney that the right and MORAL thing to do would be to give him several years of indemnity in one lump sum to enjoy and then have the rest put into a trust that provided him with weekly checks for the remainder of his life.  That way, he would have a guaranteed steady flow of funds that met his needs with a little extra.

This was a very long-winded message, I know.  But, I just wanted to apologize to you for the way many in my industry is treating you.  And, I wanted to clear my name, so to speakSmile

Take care.
 
Reply
#32
Update on our happy experience! Last week we got a call from our "helpful" NCM informing us that the adjuster had approved surgery, pending her reading the doctors report. We were, of course, relieved. My husband had seen his neuro on Thursday and we got the call that afternoon. We immediately became suspicious due to the speed of the approval and wondering how they could approve surgery prior to reading the report. Several days later, my spouse called NCM to see if a date for surgery was upcoming, only to be informed that the adjuster had "changed her mind." My spouse asked if there was documentation of the approval and was advised there was nothing in writing. She then let slip that the adjuster had been on vacation for the past week and hadn't returned. When we questioned how she could have approved surgery while on vacation, we got no response. We had also not received a copy of her report from the neuro. The attorney sent letters advising adjuster they had 2 days to approve surgery or they would petition for a hearing with the insurance commission. Within 24 hours we had approval, in writing, and a copy of the NCM report. In her report she stated that spouse had had previous back surgery on 7-12-15! It was 3 years prior! In any case surgery is scheduled in 2 weeks. For what it's worth, my spouse was married to a former NCM, who has since lost her license. She had a severe addiction to pain meds and admitted that this was the only field of nursing she could work in due to the addiction. Ultimately she could no longer even do that job. Not saying that all NCMs are addicts, but according to her it is a huge problem and the reason they work in this field. I have observed this NCM behaviour and see some evidence that there is a problem, making appointments at the wrong office, forgetting which insurance company she is dealing with, her "disconnected" attitude during office visits. Hopefully we will have little contact with her from this point on.
 
Reply
#33
GKellyGreetings all.  

I am a workers' compensation claims adjuster in Louisiana.  I've been doing this for about eleven years.  I sometimes refer to the workerscompensation.com section relating to the laws and statutes.  I had never looked at the forum but the other day I decided to check it out, just out of curiosity.

I have to say, I am completely in shock at so many of your experiences with your adjusters!  I work for a company that apparently is not the norm.  It's a small office; five adjusters and a Manager.  Our Manager has always instilled in us to do the right thing by the injured worker; both legally AND morally and by nature, all of the adjusters welcome the 'authorization' to do that.  

In all of my eleven years and hundreds of claims that I've handled, it is very rare that I out and out deny a recommended course of treatment. Example:  One of those denials was a request for Viagra for a fractured index finger.  Due to the fact that the injured worker was not on any injury-related medication that would interfere with that 'ability' and the injury itself was not the cause of that 'condition';  well, it just didn't fit the 'reasonable and necessary' definition and, his physician, chosen by him, couldn't relate it.  The injured worker had a great sense of humor and understood why I couldn't authorize it.  But, that's my point.  I've only denied those things that in no way, shape or form were related to the injury or through indisputable evidence it was learned that the injury was not work related and could not be covered under workers' comp.  There have been several times that I've had the displeasure of learning, through a phone call from a relative, that the individual was faking an injury, was collecting wage-replacement (indemnity) benefits and was either working with friends for cash or had gone to work someplace else (even though their doctor said they were TTD).  And, even in those cases, I didn't terminate benefits until I gave them and their attorney  the evidence that proved the fraud and gave them numerous opportunties to voluntarily dismiss the claim so I wouldn't have to drag them (both the injured worker AND the attorney because the attorneys  knew each one was a fradulent case) before the Court or press formal charges.  Unfortunately, there ARE some that will be dishonest to some degree and that's just reality.  Those few dishonest ones are irritating to me because they take valuable time away from me; time  that needs to be spent on those legitimate claims in order  to keep them running smoothly with as little inconvenience and disruption to the injured worker's life as possible, under the circumstances.  

Unfortunately, a few bad apples can cause an adjuster to become jaded and suspicious of each and every claimed injury. I however, am not one of those adjusters.  I've had  many injured workers tell me that I was nothing like the horror stories they had heard about workers comp adjusters. After reading these posts, I see what they were referring to.

Those adjusters that are putting some of you through h**l, give fair, decent, compassionate adjusters like me a bad name and I am so disappointed that you all are being treated so unfairly by a system that was designed to help you when you had a work-related injury.

As an adjuster who works very hard on your behalf, it hurts to read on here that the majority of you despise 'me' and feel like I am walking evil.  I assure you, not all of us are bad.  Some of us truly do care and will go above and beyond to make sure that you are taken care of and receive the treatment you need and/or want so that you can return to your pre-injury condition or as close to that as possible.  

And, as far as settlements go, for those claims that settlement is appropriate, not all adjusters will try to short-change you.  Where I work,  my Manager would kick us to the door if we even tried to give you less than what your claim is worth (fortunately, no one in OUR office wants to give you less).  I had claim several years ago that was ready for settlement.  The injured workers' attorney provided me with his evaluation and the number that his client would settle for - $80,000.00. I did my own evaluation; his client's claim was actually valued at $318,000.00. Only about $25,000.00 of that was medical as he only got one medication and saw the doctor once a year.  Can you guess what I settled for?  Yep - $318,000.00.  Although his attorney wanted this all up front, (bigger fee) I didn't do that.  Not because I'm mean. You see, this individual was an older gentleman who had dropped out of school in the 7th grade and did not have the capacity to effectively manage such a large sum of money. This money had to last him for the rest of his life because he couldn't work anymore.  If he would have been given it all, he would probably have been broke within a year because I'm pretty sure he would have been generous to the people around him.  I convinced his attorney that the right and MORAL thing to do would be to give him several years of indemnity in one lump sum to enjoy and then have the rest put into a trust that provided him with weekly checks for the remainder of his life.  That way, he would have a guaranteed steady flow of funds that met his needs with a little extra.

This was a very long-winded message, I know.  But, I just wanted to apologize to you for the way many in my industry is treating you.  And, I wanted to clear my name, so to speakSmile

Take care.

Thanks for posting Gkelly.

I for one appreciate your post and I am aware and I'm sure most of the people that post and/or read this forum are aware that there are true professionals in the business that do care for those that are caught up in a whirlwind and most of are here to vent our frustrations and/or we're being taken for a ride.  The majority of w/c cases are settled appropriately (I'm assuming btw) and there's always the ones that are working the system to their advantage.  Every case is different and my issues aren't with the insurance company; they've followed the rules in my case (mostly) and unless I'm mistaken they are profit driven and have to keep the client (employer) not just happy but demonstrate that they have their best interests in mind.  But not by treating injured workers poorly, rudely, and by not encouraging them to get well and get back to work.  My issues are with my employer and one of my surgeons.  I've been in my profession for many years and have had an injury or two but in my line of work you're going to get hurt.  Unfortunately, I couldn't work through the injury I sustained.  It's been over 2 years and 2 major surgeries and I'm still looking at a long rehab and probably a couple more surgeries.  As a lot of folks here can attest, damage to your cervical spine and a subsequent fusion (3 levels for me) doesn't always mean you're "fixed".  My employer, who I have always respected, had an issue with ME causing his insurance premiums to go up. 
A large part of my time on w/c has been on some sort of opioid meds and you're just not that sharp.  I still suffer 24/7 but had to taper off and quit taking them.  I had become physically dependent and found it impossible to make sound decisions concerning my care.  I haven't taken anything more than Advil for 6 1/2 months.  When I read the words "Opioid dependent" on one of my charts I was horrified and I'm sure red flags are raised. 
Thanks again for your post and everyone's situation is different but similar.
 
Reply
#34
(12-11-2010, 12:10 AM)GKelly Wrote: Greetings all.

I am a workers' compensation claims adjuster in Louisiana. I've been doing this for about eleven years. I sometimes refer to the workerscompensation.com section relating to the laws and statutes. I had never looked at the forum but the other day I decided to check it out, just out of curiosity.

I have to say, I am completely in shock at so many of your experiences with your adjusters! I work for a company that apparently is not the norm. It's a small office; five adjusters and a Manager. Our Manager has always instilled in us to do the right thing by the injured worker; both legally AND morally and by nature, all of the adjusters welcome the 'authorization' to do that.

In all of my eleven years and hundreds of claims that I've handled, it is very rare that I out and out deny a recommended course of treatment. Example: One of those denials was a request for Viagra for a fractured index finger. Due to the fact that the injured worker was not on any injury-related medication that would interfere with that 'ability' and the injury itself was not the cause of that 'condition'; well, it just didn't fit the 'reasonable and necessary' definition and, his physician, chosen by him, couldn't relate it. The injured worker had a great sense of humor and understood why I couldn't authorize it. But, that's my point. I've only denied those things that in no way, shape or form were related to the injury or through indisputable evidence it was learned that the injury was not work related and could not be covered under workers' comp. There have been several times that I've had the displeasure of learning, through a phone call from a relative, that the individual was faking an injury, was collecting wage-replacement (indemnity) benefits and was either working with friends for cash or had gone to work someplace else (even though their doctor said they were TTD). And, even in those cases, I didn't terminate benefits until I gave them and their attorney the evidence that proved the fraud and gave them numerous opportunties to voluntarily dismiss the claim so I wouldn't have to drag them (both the injured worker AND the attorney because the attorneys knew each one was a fradulent case) before the Court or press formal charges. Unfortunately, there ARE some that will be dishonest to some degree and that's just reality. Those few dishonest ones are irritating to me because they take valuable time away from me; time that needs to be spent on those legitimate claims in order to keep them running smoothly with as little inconvenience and disruption to the injured worker's life as possible, under the circumstances.

Unfortunately, a few bad apples can cause an adjuster to become jaded and suspicious of each and every claimed injury. I however, am not one of those adjusters. I've had many injured workers tell me that I was nothing like the horror stories they had heard about workers comp adjusters. After reading these posts, I see what they were referring to.

Those adjusters that are putting some of you through h**l, give fair, decent, compassionate adjusters like me a bad name and I am so disappointed that you all are being treated so unfairly by a system that was designed to help you when you had a work-related injury.

As an adjuster who works very hard on your behalf, it hurts to read on here that the majority of you despise 'me' and feel like I am walking evil. I assure you, not all of us are bad. Some of us truly do care and will go above and beyond to make sure that you are taken care of and receive the treatment you need and/or want so that you can return to your pre-injury condition or as close to that as possible.

And, as far as settlements go, for those claims that settlement is appropriate, not all adjusters will try to short-change you. Where I work, my Manager would kick us to the door if we even tried to give you less than what your claim is worth (fortunately, no one in OUR office wants to give you less). I had claim several years ago that was ready for settlement. The injured workers' attorney provided me with his evaluation and the number that his client would settle for - $80,000.00. I did my own evaluation; his client's claim was actually valued at $318,000.00. Only about $25,000.00 of that was medical as he only got one medication and saw the doctor once a year. Can you guess what I settled for? Yep - $318,000.00. Although his attorney wanted this all up front, (bigger fee) I didn't do that. Not because I'm mean. You see, this individual was an older gentleman who had dropped out of school in the 7th grade and did not have the capacity to effectively manage such a large sum of money. This money had to last him for the rest of his life because he couldn't work anymore. If he would have been given it all, he would probably have been broke within a year because I'm pretty sure he would have been generous to the people around him. I convinced his attorney that the right and MORAL thing to do would be to give him several years of indemnity in one lump sum to enjoy and then have the rest put into a trust that provided him with weekly checks for the remainder of his life. That way, he would have a guaranteed steady flow of funds that met his needs with a little extra.

This was a very long-winded message, I know. But, I just wanted to apologize to you for the way many in my industry is treating you. And, I wanted to clear my name, so to speakSmile

Take care.

Thank you for sharing. I was an Assistant Store Manager and my Store Manager was a very cruel person that wanted everyone to fear her. She would not promote me unless I treated everyone as if they were worthless, creating a very stressful environment. All her other Store Manger friends were like her. I never allowed her to change me, and don't you allow it either. I appreciate your words, especially with the h--l I have gone through. I am happy there are adjusters with a heart, I had one with my people, so I know it exists.
 
Reply
  


Possibly Related Threads...
Thread Author Replies Views Last Post
  Adjuster doesn't communicate with me. Tiberius 2 1,489 11-21-2016, 04:05 PM
Last Post: California_Help
  my adjuster changed my mpn ka107 2 1,274 07-18-2016, 03:04 PM
Last Post: California_Help
  Need help in adjuster hell! lilrose 3 2,617 03-29-2016, 12:39 AM
Last Post: 1171
  Dealing with WC Adjuster and Lawyer/ GA corawilke 2 2,739 09-10-2014, 10:52 PM
Last Post: Scooter123
  workers comp adjuster marcoleman 12 14,651 11-02-2012, 08:29 PM
Last Post: marcoleman
  Adjuster says claim is closed AxedmyAtty 4 5,313 03-05-2012, 10:20 PM
Last Post: AxedmyAtty
  Is it ok to call claims adjuster itzadrianyo 12 18,407 02-21-2012, 01:53 AM
Last Post: Football71
  Claims adjuster now ignoring my doctor AxedmyAtty 3 5,336 02-15-2012, 09:29 AM
Last Post: Woodlawn
  Adjuster claims to NOT KNOW I have an Attorney. inquiringMIND 5 6,014 12-10-2011, 05:20 PM
Last Post: inquiringMIND
  claims gaucli 1 2,610 03-12-2011, 07:57 PM
Last Post: 1171

Forum Jump:


Browsing: 2 Guest(s)