Determine Why the Insurer is Investigating Your Claim
If the insurer decides to first investigate your claim, an adjuster will probably contact you by phone about two weeks after you file a C-4 Claim for Compensation form at the doctor's office. The adjuster will ask you whether she has permission to record a statement. Before giving permission, you should politely ask why it is necessary for her to take a recorded statement. Try to determine whether the adjuster has a particular problem with your claim. Ask whether the employer is contesting validity. Some times the adjuster is directed to make a phone call to each injured worker assigned to her before deciding to accept or deny a claim. However, adjusters rarely have the time to do that, and usually only investigate claims that are likely to be denied.
Make A Guess Whether It Is Likely That Your Claim Will Be Denied
If you are successful in obtaining information from the adjuster about her particular concerns, you should be able to guess correctly whether your claim will be denied or not. Expect a denial if:
- There weren't any witnesses to your injury,
- You were just hired,
- You were injured on a Friday and didn't report the injury until Monday morning,
- Your employer doesn't like you,
- Your co-workers know you have pre-existing medical problems,
- You have filed multiple injury claims with other employers.
If you do anticipate that your claim will be denied, regardless of what you tell the adjuster in a recorded statement, then you might want to first hire an attorney before giving a recorded statement. Your attorney may then agree to a recorded statement, but only on the condition that it take place with the attorney present.
What to Say in the Recorded Statement
If you do give a recorded statement over the phone to the adjuster, or in person to an investigator hired by the adjuster, tell the truth. Do not volunteer unnecessary information. Give factual answers to questions about how the accident happened, when it happened, and what body parts were injured. Do not be vague about when and how the accident happened. If you are unsure about how you were injured, and you cannot describe a particular traumatic event that produced a specific injury, then your claim is likely to be denied. If you are asked about prior injuries or prior medical treatment to the injured body part, be truthful. The insurer can easily obtain information about prior work comp claims, and any car accidents you have had in the past. Your prior medical records will be obtained if the case is litigated, and you will lose credibility with the hearings or appeals officer if you were forgetful or untruthful with the investigator.
Sign Only Reasonable Authorization Forms
Read any authorization forms the adjuster asks you to sign that would enable the adjuster to obtain prior medical records. Make sure that the authorization is limited to the relevant body parts injured in this claim. You do not have to agree to having the insurer obtain all of your medical or psychiatric records if they have no bearing on what your injuries are in this accident. If the adjuster gets pushy about this, put it in writing to the adjuster that you are willing to sign all reasonable authorizations.
Cooperation is Key
You want to make it easy for the adjuster to decide to accept your claim. Anticipate what her concerns are, and ask what you can do to provide additional documentation that might address her concerns. For example, if the adjuster tells you that your employer is questioning this claim because you had a prior knee claim, you might offer to obtain your doctor's records that show you were released full duty without any ongoing problems after the prior accident. Ask the adjuster what she needs in order to accept your claim. If she needs the names of any witnesses that can verify you were hurt on the job, offer to get back to her after you get the full names and phone numbers of witnesses. Be pleasant and cooperative with the adjuster, and you are more apt to have her accept your claim. If you decline to give a statement, then your claim will be denied
Surveillance Is Allowed
Be aware that it is not a violation of your privacy for an investigator to sit in a car across from your house and film you doing yard work or working on your car. The insurer will then asks the treating physician to review the surveillance film and comment on whether the patient's activities are consistent with the claimed injury or consistent with how the patient moves when being examined by the doctor. An injured worker's attorney usually does not get a copy of the surveillance video until long after the doctor has written an adverse report. If you are truly hurt, then do not engage in activities that are inconsistent with your injury, particularly if your employer or insurer is likely to film you.
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