When a claim occurs, immediate assistance is crucial. InterWest Claim Specialists act with empathy and urgency, while providing the technical direction necessary for a fair and timely resolution.
A club member “slips, trips and falls” on wet tiles in the locker room, fracturing a wrist, and expects reimbursement for the medical treatment as well as additional compensation for stress and hardship. The club manager notifies their carrier whose adjustor contacts the injured party to take a statement and begins the process of working toward a compromise to close the claim. Several attempts are made by the manager to reach the adjuster to express concern that there was no witness to the incident and the claimant has a history of filing this type of claim. Additionally, to let them know that all potential areas for wet tiles were treated with proper anti-slip materials. These pertinent details are seemingly ignored and the club is at the mercy of the insurance carrier, while the claim and its associated costs follow the club for approximately 5 years through the underwriting process with other carriers and ultimately impacting the premiums.
A club member “slips, trips and falls” on wet tiles in the locker room, fracturing a wrist, and expects reimbursement for the medical treatment as well as additional compensation for stress and hardship. The club manager notifies their FitnessPak Claims Specialist and provide details of the incident. Immediate assistance with reporting requirements and regulatory mandates is provided and the two work together to develop an action plan. The FitnessPak Claims Specialist reports the claim to the adjustor with whom they have a professional relationship and discusses the specifics of the incident, including witnesses and the treatment of the wet tile areas with proper anti-slip materials. Serving as an advocate on behalf of the FitnessPak client, our Specialist works between the club and the insurance carrier to keep the lines of communication open to ensure a fair and timely and outcome for all concerned.
Best Practices for when a claim occurs:
- Order for Medical Attention
This should be provided by the HR Manager, Department Supervisor or Safety / Security Manager to the injured employee or medical facility at the time of treatment.
- Accident Investigation
- Employee’s Claim for Workers’ Compensation (DWC-1)
An employer is required to provide this form to the employee within one working day from the employers’ notice of injury.
- MPN Employee Handbook
Employers are required to provide this handbook to employees at the time of injury. It provides details of the Medical Provider Network and medical treatment.
- Employers Report of Injury Form (5020)
- Starts the claim process
- Allows the employer to identify when a claim is questionable
- Allows the employer to identify a potential negligent 3rd party for subrogation
- Clearly identify if employee received medical treatment or report only
- Clearly identify all red flags
- Include wage statement and job description/physical demands if injury involves lost time
- Accident and Injury follow-up form should be completed by Supervisor / Manager
- Implement a medical provider network (MPN) and exercise control
- Establish a relationship with the medical providers
- Confirm details of your return-to-work program with your provider
- Make certain the provider communicates with you (phone or fax) after employee appointments
- Report injuries promptly to their supervisor
- Obtain an Order for Medical Attention prior to seeing medical care
- Pre-designate his/her own physician or must be seen by the designated medical facility
- Report to their supervisor after each doctor visit