Claims: Anybody Can Do It!!!

27 Feb, 2013 John D'Alusio


In the course of being in the property/casualty insurance claims sector, I'm sure everyone has encountered a situation at a party or social gathering where the inevitable inquiry is posed by a guest: “So what do you do for a living?” 

The generic answer to this question is “I'm in the insurance field.” This can result in raised eyebrows and a hasty retreat, as the questioner is sure that you will now solicit him/her for a life insurance policy sale. If a more specific answer is promulgated, along the lines of “I'm in workers compensation claims,” the response can be something akin to, “Well that must be pretty straightforward. Someone is hurt while on the job and you make benefit payments.”

Of course, everyone who has ever investigated a workers' compensation claim knows that the job isn't as facile as it at first appears. Of course there are many run of the mill claims where there is no aberrant factual situation extant. However, there are certainly myriad claims where a genuine knowledge of the state WC law, jurisprudence, a keen investigative skill, and a solid grasp of medical management issues is required to successfully adjust the loss.

Additionally, there is also that pesky compensability test which requires an injury to arise out of and in the course and scope of employment in order for it to be covered under the WC Act. Simply because an injury occurs at work doesn't automatically mean it is compensable. But try explaining that to someone at a party and see how far you get before their eyes glaze over.

The fact is that WC area has as many nuances as any other area of claims, and it takes a very interested and active person to master this arena. However, to the body public, adjusting WC claims is a simple task that virtually anyone can accomplish with proficiency. My observation is that many insurance professionals look down at WC claims people. If Claims is at the bottom of the totem pole in the industry, WC claims is on the ground floor of Claims.

To me, the most annoying and insufferable situation transpires when someone without any claims experience or knowledge thinks they can adjust claims, or lead a claims Division, better than a person who was brought up in the business. I specifically recall a senior Human Resource exec at one of the companies where I worked as truly believing he was qualified to be a claims executive. Never mind that he had less than two years in the insurance industry, and had never handled a claim in his life. In his mind, it simply wasn't all that complicated. Regrettably, he wasn't the only one I encountered in my career who expressed this opinion. 

I find this attitude of “anyone can handle claims” to be somewhat amusing. I never claimed I was an HR expert, an underwriting guru, a loss prevention nabob, an actuarial wizard, etc.  Yet I have heard opinions from people in all these areas during my career who thought they knew more about claims adjusting than the denizens of the Claims Department. Of course, whenever expenses were deemed to be in need of reduction, the first area normally impacted is the Claim Department, because there are so many employees concentrated in this division. 

Naturally, insurance companies exist to sell policies, and to pay claims that arise under those policies. In order to properly handle the claims, there has to be a certain amount of bodies. But the overarching corporate attitude usually falls somewhere in the vicinity of “well, we can surely cut back 10% (or more) of the claims staff. There are so many of them.” After all, if the cut winds up being too deep, you can always hire back a few bodies because (as the saying goes) anyone can handle WC claims.

Well, I'm here to tell you that not just anyone can properly handle workers compensation claims. Simply because you are good at installing irrigation systems, plowing snow, or being an HR exec, will not make you naturally inclined to be a solid claims professional. Like any other professional career, you need to put in the time, and develop a keen interest in the tenets of the workers' compensation discipline. You have to have a sixth sense as to when something just doesn't add up, and learn a copious amount of medical terminology. You have to be able to process a great amount of information, while making sure that the plethora of WC forms that exist in most states are timely and correctly completed. You need to know when to start payments, the species thereof, and when to stop them. You have to be concerned with getting the injured individual back to work as soon as possible consistent with sound medical evidence. And you need to accomplish this on virtually every lost time file.

No, not anyone can properly handle a workers' compensation claim. But that will probably remain the opinion of superficial people who do not take the time to truly understand the significant challenges of this career choice, and who couldn't last a week in the job.

In the meantime, if you want to avoid the entire explanation the next time someone asks what you do for a living, you can simply say “I'm involved in a great social endeavor that assists the American workforce in remaining productive for as long as possible.” That should sufficiently confuse them. Of course you can always lie and say “IT,” which will probably engender the same response as if they think you are a life insurance salesperson.    


About the Author:

John D'AlusioJohn D'Alusio has over 30 years experience in P/C insurance with executive management positions in administration, field operations, and claim technical areas. Mr. D'Alusio has had many articles published in industry periodicals, and is also a contributing author to the LexisNexis published, “Complete Guide to Medicare Secondary Payer Compliance.”  He writes a monthly column for Risk & Insurance Magazine and is a quarterly columnist for AMComp Magazine.

His Risk & Insurance column is located at:




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