Jeff BrodyDivisional Safety Director, Pepsi Cola Bottling Company of New York

Kathy TazicSenior Vice President, Client Services, Sedgwick

Vicki TelfordDirector, Global Insurance and Risk Management, Hanesbrands Inc.

Tuesday, April 23, 2013Session Time: 2:15 to 3:30 p.m.

Agenda

• Claims investigation• Medical management• Disability management• Litigation management• Resolution• Updates and developments• Q&A

Claims investigation

Workers’ compensation

• What are the most important aspects of the claims investigation process?• Timely witness interviews• Detailed written report• Recorded statements where appropriate• Evidence

• Why investigate a claim?

Workers’ compensation

• Questions revolve around these four basic elements and their relationship to one another

• Develop a good checklist that helps identify the pieces of the accident “puzzle” and how they fit together

• Job safety analyses (JSAs) can be very helpful by providing the foundation of the investigation

Workers’ compensation

• Once the information is gathered, it’s time to get it off to your TPA or insurance adjuster

• Ask 5 “W” questions: who, what, where, when and, most importantly, why

• Team approach usually works best

• Take pictures and get prompt interviews

• Root causes sometimes are elusive, but without them, it’s Groundhog Day!

Workers’ compensation cost of reporting lag

< 3 Days 3 to 7 Days 8 to 13 Days 14 - 30 Days > 30 Days$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

WC Average Cost

WC Average Cost

General liability

• Work from a checklist• Develop/ personalize your form• Team effort with insured is critical• Always keep fraud in your process• Get a statement from claimant, written or recorded very

early on before they lawyer-up

General liability

Try to secure information from multiple sources

Look at the scene, take photos, is there a defect, was there notice? - get

internal report

Anyone working in the area? - canvas for

witnesses

Did claimant contribute to the event?

Was it a product that caused the accident -

who made it?

Cameras are everywhere these days!

Auto liability

• Paperwork – where is the form

• Pedestrians, bicyclists, skateboarders

• On-scene pix are essential

• Fraud – huge issue in auto liability

• By the way, whose fault is it – witnesses

• Drivers and other occupants

Auto liability

• Responders• Police, fire, EMS• Accident reconstruction• Property damage experts

• Distracted driving - telematics (technology to capture real-time info)

• Comparative negligence• Arbitration - we need

another set of eyes and ears

Medical management

Workers’ compensation

• Roles and responsibilities• Adjuster• Nurse case manager• Utilization review• Pharmacy benefit management

• What is it and why is it critical?

• Examples of medical management tools

General liability

• Sometimes we will get a second medical opinion on necessity of all treatment, issue of tangential injuries, soft tissue claims and maximum medical improvement or future care but this is usually later in the claim

• Check for priors - do an ISO search - never know what will turn up - there are way too many ‘professionals’ out there!

• Seldom do we get to manage medical treatment

Auto liability

• Medical management of your employees will be pursuant to workers’ compensation

• No fault - an opportunity for medical mills to do their $$$ thing

• Not much opportunity to manage driver/other occupants• HIPPA laws prevent prying eyes• Use activity checks – know who your claimant is and

what type of lifestyle they are leading

Disability management

Workers’ compensation

General liability

• May require second medical opinion, life care plan, modifications to home or vehicle

• Ongoing physical therapy, prosthesis, home care may be warranted

• Settlement may need Medicare approval

• Disability does not mean the end

Auto liability

• For your employees refer to workers’ compensation

• For other driver and occupants• Carefully scrutinize injury,

treatment and recovery in light of severity of collision

• Pay special attention to psych claims

• Often unable to control third party Where else? Queens, NY!

Litigation management

Workers’ compensation

General liability

• Work with counsel, share all information available, statements, photos, claim, previous history of claims from claimant, problems with the site

• Defend or negotiate a settlement - take a position

• Attend settlement/mediation hearings, have pre-arranged range of agreed upon values

• Let the attorney do the talking - but make sure you understand what he is saying and why

• Stay away from jury trials in unfriendly venues bent on giving away your client’s money

• Be ready for day of haggling - it’s an art - learn it!

• 90% of claims can resolve prior to court

Auto liability

Ability of adjuster to resolve matter prior

to litigation• Settle non-disputed

portions of the claim

Settle v. litigate - what is your preference

Work with a team of trained legal

professionals familiar with your business

• Clear understanding of your legal strategies

Resolution

Workers’ compensation

Some settlement strategies and considerations:• Adjuster negotiations• Mediations• Use of annuities

When is it a good idea to settle a claim?

What constitutes an acceptable result?

Other tools, including surveillance

General & auto liability

• Goal should be to resolve prior to attorney on board - negotiate fair settlement with pro se claimant

• If the claim is multi-part, settle what you can where liability is clear

• You can still negotiate with attorney prior to S&C – don’t be intimidated - use mediation or arbitration if far apart

• Review defenses and immunities early on, if counsel agrees, seek a motion for summary judgment (MSJ)…if not:

• Fact find from involved parties, witnesses and experts

• If unfavorable – negotiate settlement

• Don’t be intimidated by a huge med file

• Use settlement or mediation when possible - if you can’t settle within range of comfort, get ready to defend

Updates and developments