As long as you are located in a central office of an insurer, outside of West Virginia, and adjust claims only by telephone, e-mail, facsimile, regular or overnite mail, or similar methods of communication and never set foot in West Virginia.
YOU MUST SEND THE CLAIMANT A BROCHURE!
Soon after the receipt of a claim, but no later than the date of the initial decision, the insurance carrier must send the claimant a brochure outlining the claims process
YOU MUST CREATE YOUR OWN BROCHURE!
The brochure must be approved by the Insurance Commissioner and include information on who the claimant should contact, including address and telephone number, an explanation of the claims process, how and when an appeal of the decision may be taken, eligibility for benefits if time from work is missed, independent medical examinations, returns to work, choosing a treating physician, changing a treating physician and obtaining medications.
YOU MUST CREATE YOUR OWN FORMS!
While there are some forms on the Insurance Commissioner's web site which may be modified to your use, there are no standard required forms for denials or to notify workers of amounts of compensation payable.
YOU ARE THE JUDGE!
Any claims management decision by either the private carrier or a self-insured employer may be contested and appealed. Thus, the decision of you, the claims adjuster, is the equivalent of an appealable Order.
YOU ARE THE SOLE VOICE OF THE EMPLOYER!
Section 85-1-7.3 provides that in claims where there is insurance coverage, the private carrier has the sole authority to act on behalf of the employer in the claim (including making claims decisions, appointing counsel for the defendants and directing litigation strategy).
TIME IS OF THE ESSENCE!
You have 15 days to make a decision on a new claim unless you notify the claimant that additional information is needed. When you render a decision, a Notice of Decision must be sent to the claimant advising of the basis of the decision and the claimant's right to file a protest with the Office of Judges within 60 days
YOU MUST HIRE A LAWYER!
It is mandatory that a corporation be represented in Office of Judges proceedings by counsel admitted to practice in West Virginia. Thus, once an adjuster's decision is protested, you must retain counsel.
YOU SHOULD HIRE A LAWYER!
You should consider retaining counsel early in the in the investigative process of complex claims or ones where a protest is anticipated as time for discovery will be limited before the Office of Judges. The Administrative Law Judge will expect that most discovery is complete by the time the case reaches the judge's desk. Thus, the case is essentially "in litigation" from the moment it is reported to you. Counsel can assist in gathering and preserving evidence under the protection of attorney client privilege. Counsel can conduct in person on site interviews and investigation that unlicenced out of state adjuster cannot. Additionally, counsel can assist in creating the necessary brochure and forms.
YOU MUST READ RULE 1 FROM BEGINNING TO END AND UNDERSTAND IT BEFORE YOU ADJUST YOUR FIRST CLAIM!
Rule 1 of the Workers' Compensation rules governs claims management and administration. It may be found at http://www.legis.state.wv.us/WVCODE/code.cfm?chap=23&art=1. Rule 1 establishes the requirements and procedures to be followed by all entities involved in the administration of Workers' Compensation claims.
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