Claims Management - Open Claims

Question 1

What two questions should adjusters ask themselves every time they review an open claim?

Answer 1

• What do I need to do to bring this claim to resolution?

- Are my reserves adequate?

Question 2

How many days does the insurer have to reclassify a claim from nondisabling to disabling?

Answer 2

• The insurer has 14 days from receipt of information that the claim is disabling
  or
  -A request from the injured worker to reclassify the claim.
  -If it is more than one year from date of acceptance, the injured worker must file an aggravation claim.

Question 3

When a worker is represented by an attorney, when do you need to provide discoverable documents?

Answer 3

14 days from the request from the attorney

Question 4

When a worker is represented by an attorney How often and for how long do you need to provide updates?

Answer 4

provide updates every 30 days for 180 days

Question 5

Why is it important to set reserves on a claim?

Answer 5

• It enables SAIF to estimate future liabilities.
• Reserves are used in ratemaking and calculation of the employer’s modification rate.
• It is used to calculate premium for retrospective policies.
• Reserves facilitate underwriting decisions.
• It meets statutory requirements.

Question 6

In what four areas is a claims adjuster responsible for setting reserves?

Answer 6

• Medical,
• Temporary Disability (Time loss),
• Permanent Partial Disability,
• Legal Costs (Fees)

Question 7

When is an adjuster required set reserves on a claim?

Answer 7

• Within 30 days of the receipt of the request for hearing on a denied claim or condition.
• Within 30 days of acceptance of a disabling claim.
• On accepted, nondisabling claims, when medical paid costs exceed $5,000

Question 8

What are examples of significant events that would prompt you to review the reserves on a claim?

Answer 8

• A change in the time loss authorization (starting or stopping)
• A change in the work release or work status
• Receipt of medical information such as a surgery
• Claim closure information
• A request to reopen a claim
• A request to accept new, omitted, consequential, or combined conditions
• The passage of time without further treatment or activity in the claim