Insurance Adjusters in Workers’ Compensation Claims in PA
Insurance adjusters play a major role in Pennsylvania workers’ compensation claims by investigating work injuries, determining whether claims are accepted or denied, and managing benefits throughout the process. Because insurance adjusters work for the insurance company, injured workers should be careful when communicating with them and understand how their statements may affect a workers’ compensation claim.
In every workers’ compensation claim in Pennsylvania, four key figures are always involved: the injured employee, the employer, the employer’s workers’ compensation insurance carrier, and the insurance adjuster. Among these, the insurance adjuster plays a pivotal role in workers’ comp claims in Pennsylvania, determining the injured worker’s eligibility for benefits and overseeing the process through which those benefits are obtained.
What Do Insurance Adjusters Do in Workers’ Compensation Claims in PA?
Insurance adjusters are highly skilled professionals responsible for making critical decisions in each case. Their primary function is to determine whether an injured worker’s claim will be accepted or denied. To make this determination, adjusters investigate the claim, interview the employer about the incident and the injured employee’s job duties, and speak with any witnesses to confirm whether the injury occurred and if it was work-related.
Since the insurance company’s goal is to minimize costs, the adjuster will scrutinize the claim to identify any reason to deny it. If they find that the injury didn’t occur or isn’t work-related, they can deny the claim outright. Alternatively, if the injury is valid, the adjuster may attempt to settle quickly with a low offer or suggest light-duty work to avoid formally accepting the claim and making benefit payments.
What Happens After a Workers’ Comp Claim Is Accepted?
Once a claim is accepted, the adjuster assumes responsibility for approving medical treatments, coordinating doctor’s appointments, and tracking the injured worker’s recovery progress.
The adjuster closely monitors the situation to manage costs. They review medical records and may even conduct surveillance to assess the injured worker’s activities. If they determine that the employee has fully recovered or is exaggerating their injuries, they might initiate litigation to terminate benefit payments and close the claim.
What Happens After a Workers’ Comp Claim Is Denied?
If a claim is denied and litigation ensues, the adjuster remains actively involved. Throughout the legal process, they will:
- Monitor the injured worker’s medical treatment and progress.
- Arrange evaluations with the insurance company’s preferred medical providers.
- Make settlement offers when appropriate.
Will the Insurance Adjuster Contact the Injured Worker?
As part of their investigation, insurance adjusters often seek to take a recorded statement from the injured worker or conduct informal interviews. They may ask questions such as:
- How did the injury occur?
- Where did the injury happen?
- What were you doing immediately before the injury?
- Were there any witnesses?
- Did you seek medical treatment immediately?
- What diagnosis did your medical provider give?
- How long do they anticipate your recovery will take?
These questions are designed to evaluate whether the claim is valid. However, it’s crucial to remember that the adjuster works for the insurance company, not the injured worker. They may attempt to use the injured worker’s statements against them.
What Should an Injured Worker Say to the Insurance Adjuster?
If an injured worker chooses to speak with an adjuster, honesty is essential. However, it’s important to remember that the adjuster is not on their side. Injured workers are not required to speak directly with the adjuster. Instead, they can hire an experienced workers’ compensation attorney to handle all communications on their behalf.
By working with a specialized workers’ compensation law firm, injured workers can ensure that their rights are protected and improve their chances of receiving the benefits they deserve as quickly as possible.
Talk to a Pennsylvania Workers’ Compensation Lawyer
Insurance adjusters play a significant role in Pennsylvania workers’ compensation claims, from investigating workplace injuries to approving or denying benefits. While adjusters may seem helpful, it is important to remember that they work for the insurance company and are focused on protecting the company’s interests.
If you have been injured at work, understanding your rights before speaking with the insurance company can make a significant difference in the outcome of your claim. An experienced workers’ compensation attorney can help you navigate the process, communicate with the insurance adjuster on your behalf, and pursue the medical treatment and wage-loss benefits you deserve.
At Stern & Cohen, we help injured workers throughout Philadelphia and Pennsylvania protect their rights and fight for the benefits they are entitled to receive. Contact us today for a free consultation.
FAQs
Can an insurance adjuster deny my workers' compensation claim in Pennsylvania?
Yes. The insurance adjuster is responsible for investigating your claim and deciding whether the workers’ compensation insurance company will accept or deny benefits. If the adjuster believes your injury is not work-related or disputes the facts of the claim, the claim may be denied. However, a denial does not mean your case is over. Injured workers have the right to challenge a denial through the Pennsylvania workers’ compensation system.
Should I give a recorded statement to a workers' compensation insurance adjuster?
You are generally not required to provide a recorded statement to the insurance adjuster. Because adjusters work for the insurance company, anything you say may be used to challenge your claim. Many injured workers choose to consult with a Pennsylvania workers’ compensation lawyer before speaking with the insurance company.
Can the insurance company send me to its own doctor?
Yes. In some situations, the insurance company may require an injured worker to attend an Independent Medical Examination (IME). The doctor performing the examination is selected by the insurance company and may provide opinions regarding your diagnosis, treatment needs, work restrictions, or recovery status.
What if the insurance adjuster says my workers' compensation claim is not work-related?
If an insurance adjuster claims that your injury is not work-related, it does not necessarily mean your claim is invalid. Insurance companies often dispute whether an injury occurred at work, especially when there are no witnesses, a delayed report, or questions about a pre-existing condition. Medical records, witness testimony, accident reports, and other evidence can help establish that your injury is work-related. Even if your claim is denied, you may still have the right to pursue benefits through the Pennsylvania workers’ compensation system.