The First 72 Hours of a Lost-Time Claim

Purpose

The first 72 hours largely determine whether a claim becomes:

• A routine recovery
• A prolonged disability claim
• A litigated claim
• A high-cost claim

This playbook provides a structured approach to investigation, communication, medical management, and documentation.

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Claim Profile

Scenario

• Employee reports a back injury lifting materials.
• Missed work begins immediately.
• No attorney involvement.
• No obvious compensability concerns.

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Primary Objectives

During the first 72 hours:

✅ Determine compensability

✅ Establish rapport

✅ Direct medical care appropriately

✅ Gather facts before memories fade

✅ Identify return-to-work opportunities

✅ Set accurate reserves

✅ Document the file correctly

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The 8 Critical Questions

Every adjuster should answer these questions before day three.

1. What exactly happened?

Avoid:

"Employee hurt back lifting."

Instead capture:

"Employee lifted a 75-pound box from pallet to shoulder-height shelf and felt immediate pain in lower back."

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2. Who witnessed the event?

Obtain:

• Names
• Titles
• Contact information

Document:

• What they saw
• What they heard
• Timing consistency

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3. Was the injury reported promptly?

Questions:

• Date of injury?
• Date reported?
• To whom reported?

Red Flag:

A significant reporting delay.

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4. Is the mechanism medically plausible?

Compare:

Injury allegation

vs.

Medical records

Example:

If worker reports:

severe shoulder injury while lifting

but ER records indicate:

condition developed gradually over three weeks

investigation should expand.

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5. What work restrictions exist?

Never document:

"Restricted duty."

Document:

• No lifting over 10 lbs.
• No climbing.
• Alternate sitting and standing.
• No overhead reaching.

Specific restrictions drive return-to-work planning.

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6. Is modified duty available?

Contact employer.

Ask:

• Can restrictions be accommodated?
• Temporary assignment available?
• Transitional duty program?

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7. Are there recovery obstacles?

Potential obstacles:

• Transportation
• Language barriers
• Prior injuries
• Chronic pain history
• Labor dispute
• Job dissatisfaction

These do not determine compensability.

They affect outcomes.

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8. What could make this claim expensive?

Examples:

• Surgery risk
• Attorney involvement
• Comorbidities
• Delayed treatment
• Catastrophic potential
• Poor employer relationship

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Required Contacts

Injured Worker

Goal

Build trust early.

Opening questions:

• How are you feeling today?
• What concerns do you have?
• What has the doctor told you?
• What can I help you with right now?

Avoid interrogating.

Start with listening.

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Employer

Goal

Establish partnership.

Questions:

• What happened?
• Were there witnesses?
• Is modified duty available?
• Any prior issues involving this employee?
• Any surveillance or video?

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Medical Provider

Obtain:

• Work status
• Restrictions
• Treatment plan
• Follow-up appointment
• Diagnostic testing plans

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Red Flag Assessment

Not every red flag means fraud.

Red flags simply mean:

Investigate further.

Common Red Flags

• Injury Monday morning
• No witnesses
• Delayed reporting
• Conflicting histories
• Pending termination
• Significant overtime before injury
• Prior similar claims

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Medical Management Checklist

Within First 72 Hours

Review:

• Initial report
• Restrictions
• Diagnosis
• Prognosis
• Follow-up schedule

Ask:

What drives recovery?

Examples:

• Physical therapy?
• Specialist referral?
• MRI?
• Surgery consult?

Develop action plan.

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Reserve Review

Initial Questions

What is currently known?

• Medical only?
• Lost time?
• Surgery possibility?
• Attorney representation?
• Permanent impairment potential?

Common Mistake

Setting reserves based solely on diagnosis.

Example:

Two identical lumbar strains may have very different exposures depending on:

• Occupation
• Wages
• Return-to-work options
• Recovery progress

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Diary Plan

Every file should have clear next steps.

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Day 3 Diary

• Review medical note
• Verify restrictions
• Confirm employer accommodation

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Day 7 Diary

• Check treatment attendance
• Evaluate work status

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Day 14 Diary

• Recovery progress review
• Reserve review
• Settlement considerations if appropriate

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Common Adjuster Mistakes

Mistake #1

Focusing on the injury instead of recovery.

Better question:

What is preventing this worker from returning to function?

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Mistake #2

Talking only with employers.

Claimants who feel ignored often become represented.

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Mistake #3

Ignoring psychosocial factors.

People recover from injuries.

People struggle more with uncertainty.

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Mistake #4

Passive claim handling.

Good adjusters move the claim.

Poor adjusters watch the claim.

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Claim Success Scorecard

At 72 hours:

Measure	Goal
Employee Contact	Completed
Employer Contact	Completed
Medical Records Obtained	Completed
Restrictions Identified	Completed
RTW Discussion Held	Completed
Compensability Evaluated	Completed
Reserves Set	Completed
Diary Plan Created	Completed

Key Principle

The first 72 hours are not primarily about paying benefits.

They are about creating direction.

A well-managed claim begins with a clear understanding of the injury, frequent communication, realistic recovery expectations, and a documented plan for moving the worker toward function and return to work. Every action in the first three days should answer one question:

What is the next step most likely to help this claim recover efficiently and successfully?