Ethics In Workers Compensation Claims – Does It Exist?
Ethics in the Workers Compensation claims arena has increased over the years. Last week, I had the privilege of attending the 3rd Quarterly Meeting of NC PRIMA in Winston-Salem, NC. If you are in the public risk sector in North Carolina, you are definitely missing out by not being a member. The other PRIMA chapters can be found here.
The law offices of Cranfill, Sumner and Hartzog (CSH) presented at the meeting. The topic was Ethics in Workers Compensation. Overall, the presentations were very informative. CSH is one of the premiere Workers Comp defense firms in North Carolina.
Over the weekend, I read some type of innocuous article on the 80-20 rule as it applies in science experiments. I then thought that the 80-20 rule does apply to Workers Compensation ethics.
In most of my career in insurance, I have always noticed that 80% of the Workers Compensation personnel are trustworthy, forthright, and very ethical. The other 20% are another matter. I would never say the other 20% are unethical all of the time. The phrase “hit and miss” would apply in these cases.
The 20% to which I am referring are not unethical ALL of the time. I will coin the term spot-ethics or almost always ethical except in certain instances. The spot-ethics are sometimes fostered by the TPA (Third Party Administrator) or insurance company office.
Some of the questions that ran through my mind after the CSH presentation were:
- Should an adjuster deny a claim just to settle the file for a cheaper amount later than paying all benefits upfront?
- Should adjusters alter forms that were signed by the injured employee just to make sure they will be approved by the WC regulatory board or commission as long as they do not affect the amount of benefits payable?
- Does the adjuster use the same guide each time when taking recorded statements?
- If an adjuster skips a check by mistake, should they blame the mail, and then issue a check that was never issued in the first place?
- Should the oldest medical bills be paid first and not on an ad-hoc basis?
- Is the file documented with clear concise notes that are not handwritten?
- Is over-reserving or under-reserving a file unethical?
- Is an adjuster considered unethical if they accidentally make a mistake?
After pondering whether or not most claims personnel are ethical, I would have to say that the 20% was somewhat extreme. My assessment is that 5% of claims personnel are unethical at some point in their career. This does not mean they are unethical from day one. Are the questions I posed really a question of ethics? Some of them are – others are not.
CSH had a great list of ethical considerations for adjusters and risk managers that apply to any state:
- Encourage prompt reporting of injuries
- Act with a sense of urgency
- Complete a prompt and thorough investigation
- Have a legitimate and arguable basis for any denial
- Competent and objective professionalism
- Document notes completely and objectively
- Authorize medical treatment timely
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