Workers' Compensation Claim Services

About Our Claims Service. . .

Our experienced claims personnel are capable of investigating and servicing large volumes of claims from the onset to conclusion with minimal effort on behalf of the insurance carrier or self-insured employer. Our services include complete, thorough investigation of all claims to determine compensability with emphasis on professional, quality claims service.

Our commitment is to provide fast, fair claims adjusting in legitimate claims with emphasis on professional, uncompromising quality claims service. We believe the consistent process of sound, ethical claims practice not only enhances the best interest of the clients we serve but also ensures an atmosphere of confidence and trust with the injured employee, which is essential to the most desireable results being accomplished in a minimal amount of time.

The Concept

• Soliciting of Employer’s First Report of Accident from responsible parties ensuring prompt and timely reporting of legitimate work related injuries.

• Procedural reporting of all compensable lost time claims pursuant to the requirements of Industrial Commissions or Workers’ Compensation Boards.

• All lost time accidents thoroughly investigated to determine compensability, questions of causal relationship and/or jurisdiction. Investigation will include, but not be limited to, the following:

Interviewing injured worker relative to work-related injury.

Interviewing employer and witnesses to verify accident details.

Securing wage transcript from employer to establish accurate average weekly wage.

Securing medical evidence from attending physicians covering history, diagnosis, causal relationship, treatment and prognosis.

Reporting to Index Bureau.

Providing a summary report to self-insured employer or insurance carrier reflecting compensability judgment and recommendations for future handling.

• Conference with pre-designated personnel with self-insured employer or insurance carrier for authorization to enter into agreement for payment of compensation in compensable claims.

• Timely payment of compensation conforming to statutory requirements.

• Timely payment of medical bills incurred in conjunction with injured employee's work-related injury.

• Thorough monitoring of all claims during injured employee's incapacity ensuring medical evidence supports continuing disability and employee keeps all follow-up medical appointments on a timely basis.

• Consistent follow-up with injured employee at appropriate intervals commensurate with employee's nature of injury and anticipated period of disability.

• Statistical form reporting conforming to statutory requirements.

• Preparation of necessary documents in compliance with statutory requirements to affect voluntary termination of payment of benefits.

• Preparation of applications or petitions, along with supporting documentary evidence, in compliance with statutory requirements and filing with appropriate forum seeking termination of payment of benefits when justified.

• Arranging final medical examination to determine extent of permanent disability, if any, in claims requiring final medical examination.

• Appropriate adjustment of permanent disability claims.

• Continuous claims development to affect lump-sum settlements where permitted by statute

• Referral for independent medical examination if it appears maximum improvement has been reached and the employee may be malingering or if questions of disability, causal relationship or treatment exist.

• If return to regular pre-injury employment does not appear medically feasible, the return to modified or selective work consistent with the injured employee's medical and/or physical limitations will be explored and thoroughly exhausted.

• Thorough review of all medical bills to ensure reasonableness and necessity of charges.

• For reference in determining reasonableness and necessity of charges, utilization of professional fee schedules, medical cost surveys and/or relative value studies.

• Audits of hospital and/or doctor bills including review of inpatient/outpatient medical records, hospital charts, drug and therapy charges for purpose of reducing and deleting charges for services not rendered.

• Prompt payment of all legitimate medical bills to medical provider within thirty calendar days.

• Exhausting vocational rehabilitation resources in the form of alternate work, modified work and/or job placement, i.e., job restructuring for disabled employees.

• Arranging vocational evaluations to determine feasibility of vocational rehabilitation training when all efforts to restore employee to gainful employment have been exhausted and proven futile.

• Arranging for vocational rehabilitation training and appropriate follow-up and monitoring to ensure desired results are accomplished.

• Social Security offsets

• Third party recovery (subrogation)

• Activity/dependency checks

• Prompt notification of denial to appropriate parties with subsequent vigorous defense provided for all contested claims.

• Continuous supervision of pending litigation

Hearings: Reference Legal Support

• Complete pre-trial defense preparation in the areas at issue.

• Pre-trial arrangements for all necessary lay and professional witnesses to be available at hearing.

• Timely pre-trial delivery of litigation file to legal counsel.

• Attending industrial hearings to assist in the defense of contested claims, traumatic and occupational disease.

• In litigation claims, appropriate pre-trial strategy will be employed to ensure most desirable results possible are attained.

• Compromise settlements based on sound claims practice and judgment consistent with benefit structure and potential liability of claim.

• Summary report covering compromise lump-sum settlements.

File Activity:

• File activity thoroughly documented with copy simultaneously forwarded to self-insured employer or insurance carrier.

• Surveillance

• Hearing loss

• Disfigurement

• Idiopathic falls

• Ingress & egress

• Partial wage loss

• Product liability

• Independent contractors

• Occupational dermatitis

• Anxiety/traumatic neurosis

• Mutual mistake of fact/fraud

• Cost of living increase entitlements

• Foreign injuries/jurisdictional issues

• Total/partial dependency

• Parents in destitute circumstances

• Desertion

• Stroke/heart attack

• Death due to coal workers' pneumoconiosis

Willful Misconduct:

• Suicide

• Horseplay

• Intoxication

• Intentional self-inflicted injury

• Growing out of attempt to injure another

• Willful failure or refusal to use or observe a safety appliance or regulation

Investigation will include, but not be limited to, the following areas as applicable:

• Medical history

• Employment history

• Waivers

• Referral of chest x-ray films for rereading by "B" reader radiologists, or alternatively, arranging for independent chest x-ray examinations

• Referral for independent pulmonary evaluations

• Case summary/pre-trial defense preparation

• Administrative compliance lump-sum settlements and awards

Administration of any private medical or disability insurance plan coordinating payment of benefits and ensuring administrative compliance conforming to the general purpose, scope and benefit structure of the plan with emphasis in cost control.

OTHER AREAS OF SPECIAL INTEREST

• Pre-employment physical programs

• Loss control (accident prevention) programs

• Structured settlements

INSTANT OVERVIEW

• Third Party Administration

• Investigation for Compensability

• Claims Adjusting

• Litigation Supervision

• Preferred Provider Networks

• State & Federal Black Lung Supervision/Defense Preparation

• Physician Paneling Programs

• Longshore & Harbor Workers' Claims

• Activity Checks

• Dependency Checks

ERVIN B. DAVIS & COMPANY, INC.

"A Company that can and will deliver the claim service promised"

www.ebdc.com

ebdc@netscope.net