Insurance Adjusters in Workers’ Compensation Claims in PA
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.
Contact Stern & Cohen Today
If you’ve been injured at work in Pennsylvania, contacted by an insurance adjuster regarding a workers’ compensation claim, or need assistance with any aspect of your claim, don’t hesitate to reach out to Stern & Cohen.