What Insurance Adjusters Won’t Tell You: Workers Comp Claim Adjuster Tricks and Techniques
Learn How to Handle the Games Workers Comp Adjusters Play So You Can Maximize Your Claim’s Value
After you report a work injury to your employer, a workers comp claim adjuster will call or write to you.
This adjuster works for your employer’s insurance carrier. Or, if your employer is self-insured, the adjuster likely works for a third-party claim administrator (TPA) such as Sedgwick CMS, Gallagher Bassett, ESIS, or CorVel.
The workers comp adjuster’s goal is to save your employer and the insurer money. And the adjuster does this by finding ways to terminate your claim as cheaply as possible – through an aggressive defense or a low settlement offer.
This article explains typical workers comp adjuster tricks so that you can recognize and overcome them.
You will interact with the adjuster frequently, especially if you do not hire a workers compensation lawyer to prosecute your claim. And I want you to know the games insurance adjusters play and how to deal with them to get the best result possible.
Keep reading to learn more about strategies used by workers comp adjusters to lower your payout. And then check out my article on how to scare the insurance adjuster for more proactive ways to increase your claim’s value.
My law firm represents injured workers throughout the state. If you have any questions about workers compensation law or want to discuss potential negligence and tort claims against the person who harmed you, call me at (804) 251-1620 or (757) 810-5614.
When Does the Workers Comp Claim Adjuster Get Involved?
Your employer should tell its workers compensation insurance carrier (Travelers, The Hartford, Liberty Mutual, etc.) about your occupational injury or illness as soon as you report it. Many (if not all) insurance policies require prompt notice from the employer so the insurer can investigate the claim.
Once it receives notice of the workplace accident or the diagnosis of an occupational disease, the insurance company will assign a claim adjuster to your case.
Many insurers and TPAs have claims management manuals requiring an adjuster to send a letter or call you within a specified period to ask for information. For example, the adjuster will likely contact you within 48 hours of the injury, offering to meet you at home or a nearby coffee shop. And I have even heard of claim adjusters showing up at the hospital after a construction accident resulting in catastrophic injuries (a concussion and a back injury ultimately requiring spinal fusion) when the employee is on pain medication or hooked up to an IV.
What Does a Workers Comp Claim Adjuster Do?
A claim adjuster evaluates and manages insurance claims.
Claim adjusters have a role in most tort claims seeking damages for personal injury, including car crash lawsuits and workers comp. They even make initial determinations for long-term disability insurance claims.
In occupational injury claims, insurance adjusters gather facts and determine whether you should get workers compensation under your state’s law. And, if so, what types of workers comp benefits to pay and how much money to offer to settle the claim and close out medical treatment.
Workers comp adjusters may do the following things to complete these tasks:
- Review your employer’s workers comp insurance policy to confirm coverage on the accident date.
- Verify your pre-injury average weekly wage, which is the number that determines how much you will receive in temporary total, temporary partial, and permanent partial disability payments.
- Confirm that you were an employee, not an independent contractor.
- Interview accident witnesses to look for potential defenses, including willful misconduct or violating a safety rule (such as not wearing a seat belt).
- Determine if you gave timely notice of the workplace accident and the injuries claimed.
- Obtain post-injury wages, if applicable
- Communicate with your pre-injury employer to determine if it can accommodate any light-duty medical work restrictions you receive
- Refer the file for surveillance if there are red flags to suggest malingering (faking a disability) or fraud.
- Authorize or deny medical treatment for your work injuries, including surgical referrals or second opinion requests.
- Contact your authorized treating physician for additional information on causation and disability from work.
- Refer you for an Independent Medical Examination (IME) if they do not like what your treating doctor said about causation or disability from work.
- Authorize the payment of indemnity benefits or mileage reimbursement.
- Coordinate transportation to medical appointments
- Refer your claim to insurance defense counsel to see if there are any valid defenses to your workers comp claim.
- Hire expert witnesses to testify if a workers comp hearing is necessary.
- Refer you for a Functional Capacity Evaluation (FCE) if you have reached Maximum Medical Improvement (MMI).
- Decide whether to start vocational rehabilitation services to get you back into the labor force and reduce the employer’s financial liability for your work injury.
- Communicate with vendors to determine the appropriate Workers Compensation Medicare Set Aside Arrangement (MSA) amount.
- Handle subrogation issues and negotiate liens if you have a third-party action arising from the work injury. For example, these issues often arise in work-related motor vehicle crashes.
- Respond to compliance requests from the Workers Compensation Commission.
In my experience, workers comp adjusters are highly trained, skilled, and specialized. Indeed, the adjuster assigned to your claim likely handles similar cases. For example, some insurers classify adjusters as lost-time adjusters, medical-only adjusters, or catastrophic claims adjusters (handling traumatic brain injury, amputation, burn, and spinal cord injury cases).
What is the Workers Comp Adjuster’s Caseload, and Why Should It Matter to Me?
Knowing how many claims your workers comp adjuster handles at once is essential because it helps you understand what the initial investigation may look like. And how responsive the claim adjuster will be to your questions and needs.
Generally, the more cases the adjuster has, the less thorough the accident investigation and the more details the adjuster will miss. This lack of attention to detail could help you, resulting in a quick decision to pay benefits and offering a Workers Compensation Award Letter.
On the other hand, dealing with a busy claims adjuster can result in frustration. For example, you may find reaching your workers comp adjuster difficult when your checks are late or medical treatment needs to be authorized.
A busy insurance adjuster may also take longer to respond to your demand letter asking for a lump sum for settling your workers comp case, causing the claim to stay open longer than needed. This delay means waiting for a fresh start after an occupational injury.
In my experience, workers comp adjuster caseloads are as follows:
- Medical-Only Workers Comp Claim Adjusters: 300 to 400 cases at a time.
- Lost-Time Workers Comp Claim Adjusters: 200 to 300 cases at a time
- Catastrophic Workers Comp Claim Adjuster: 100 to 200 cases at a time
As you can see, many workers comp adjusters are overworked, affecting their response time.
And this delay can damage your health and finances.
Does the Claim Adjuster Have to Tell Me My Rights Under Workers Comp?
No.
The workers comp adjuster works for the employer or insurance carrier, not you.
And because you do not have a first-party insurance claim, the adjuster does not have to explain the workers comp rules and regulations to you.
Instead, you must develop the evidence needed to satisfy your burden of proof (preponderance of the evidence in most cases; however, clear and convincing in others). The adjuster does not have to do this for you.
22 Common Workers Comp Adjuster Tricks and Tactics – And Ways to Counter Them
Workers comp adjusters use specific techniques to investigate, defend, and negotiate claims settlements.
These adjuster strategies are lawful but will still hurt your case if you don’t know what to watch out for or when to refuse the adjuster’s requests.
Below are the most common insurance adjuster tricks I see, with my suggestions for how to respond to preserve your claim’s value.
Adjuster Trick #1: Asking You to Give a Signed or Recorded Statement Soon After the Work-Related Accident
Many insurance companies require their adjusters to ask the injured employee for a recorded statement as part of the claim investigation.
There are several reasons for this. And not all of them are good. For example, the adjuster may use the recorded statement interview to ask leading questions and to:
- Get you to admit to facts that prove you did not suffer an injury by accident arising from a specific employment risk. For example, the Virginia Workers Compensation Act does not cover repetitive motion/cumulative trauma injuries. Therefore, the adjuster may push you toward a vague statement on how the accident happened at work but not ask you to identify a specific incident.
- Fish for harmful information, such as past work or motor vehicle accidents.
- Ask about your criminal history, including specifics you do not have to provide during pretrial discovery.
- Find out your family’s financial situation to determine if you are desperate and likely to accept a low settlement offer.
- Assess your credibility and whether you would make a good witness at trial. If the adjuster thinks you will struggle with this aspect, they may look harder for a way to defend the case.
- Pin you to a version of events that will make you look like a liar if you change your testimony at trial.
To cooperate with their employer and insurance company, I have seen many injured employees give recorded statements that end up causing severe damage to their claims.
But there is good news.
You do not have to give a recorded statement to the insurance adjuster.
And you shouldn’t. You have the right to keep silent. And I recommend exercising it even if the adjuster says you must give one.
Click here for more information on Recorded Statements in Workers Comp Cases.
Adjuster Trick #2: Asking You to Sign a Blank Medical Authorization Form to Get Whatever Medical Records They Want
The demand for a recorded statement is not the only workers comp adjuster’s request you should reject after an occupational injury.
Many of you will receive a letter or an email from the adjuster asking you to sign a Medical Authorization form.
This form directs your medical providers (doctors, surgeons, nurse practitioners, etc.) to release your medical records to the insurance adjuster.
In my experience, many injured employees sign and return these blank records releases immediately, hoping the insurance adjuster will reward this compliance by paying benefits quickly. But unfortunately, this happens rarely.
And you should not sign the paper.
Although the insurance company can obtain and review medical records related to the work injury and other health care in the past ten years, you do not have to release your complete medical history with no limits.
In addition, you do not have to permit the adjuster to speak with your treating physicians.
Further, the more medical reports you allow the insurer to get, the more likely the adjuster will find some reason to deny your claim. For example, the adjuster may refuse to pay benefits without a fight because you have pre-existing conditions or past accidents that could contribute to your pain.
For more information on how to respond to the adjuster’s request that you sign a Medical Authorization form, read my article: Do I Have to Sign a Medical Records Release to Recover Monetary Damages in a Personal Injury Case or Get Workers Comp?
Adjuster Trick #3: Telling You that Hiring a Workers Comp Attorney Will Cost You Money or Slow Down Your Claim
Claim adjusters know that when an injured employee hires a workers comp attorney, there is a good chance that: 1) the insurance company will have to pay more money in benefits or a settlement and 2) the claim will take more effort to terminate.
To avoid this, the adjuster may contact you quickly before you can call or speak with an attorney and start out playing nice, making you believe they have your best interest at heart.
They may also try to convince you not to hire a lawyer by saying things like this:
- I will not pay you more because you hired an attorney.
- I will send your file to a defense attorney if you hire a lawyer.
- Hiring a lawyer slows down the claims process.
- You will get less money in your pocket after paying a fee to the attorney.
Many of these statements are myths, not based on facts.
Hiring a lawyer can make your claim faster because the attorney knows what pleadings to file, pretrial discovery requests to make, and evidence to develop.
In addition, the attorney’s knowledge of how to build a strong claim can increase your case’s value.
For example, one study found that injured employees with attorneys recovered almost three times as much money as unrepresented employees.
Further, the Workers Compensation Commission regulates attorney fees to ensure the charge is fair for the results obtained.
Adjuster Trick #4: Refusing to Answer Phone Calls or Emails
Many injured employees call me because the workers comp adjuster ignores their phone calls and emails.
And the documents I receive in pretrial discovery, including the adjuster’s file, often show how bad this problem is.
For example, I have reviewed adjuster notes indicating it takes multiple voice messages and emails before the adjuster responds to the claimant.
This avoidance technique aims to get you to give up or feel too inconvenienced to pursue your claim.
Adjuster Trick #5: Saying the Investigation is Ongoing to Avoid Having to Provide An Agreement Form
The adjuster may respond to an initial claim for benefits, change-in-condition application, settlement demand, or 30-Day Order from the Workers Compensation Commission by saying the investigation in ongoing.
This is a delay tactic to avoid stipulating facts that help you, paying benefits, or authorizing medical care.
In this situation, ask the adjuster:
- What do you need to complete the investigation?
- What have you done to get that information?
- How much longer do you expect it to take to get what they need?
Then tell the adjuster that you will follow up in 1 week.
In addition, ask the Commission (or your state’s agency overseeing occupational injury claims) to schedule your claim for a hearing/trial.
Your actions will pressure the adjuster to finish their investigation and respond to the various requests.
Adjuster Trick #6: Trying to Control Your Medical Care More than the Law Allows
Each state has its own workers comp laws that dictate how much control the insurance company has over your medical care for an occupational injury or illness.
For example, in Virginia, the insurer must provide a list of at least three physicians from which to choose after you report the work accident.
However, some employers and claim adjusters will not tell you this. Instead, the adjuster will push you to see a doctor who they know to be defense-friendly. A defense-friendly doctor is a physician who is conservative on issues of causation and disability from work.
Or the adjuster may offer a list that does not include three separate doctors from different practice groups, making it invalid.
Know your rights and demand a physician panel. Your doctor’s opinion often determines whether you must accept a light-duty offer and whether a judge will find your ongoing disability and treatment related to the work accident instead of a pre-existing condition.
Adjuster Trick #7: Offering a Lowball Settlement Offer
The adjuster knows that workplace injuries create fear.
Indeed, the weeks following an on-the-job accident can be some of the worst of your life, not only because of the physical pain but also the uncertainty of whether you will get a paycheck and be able to provide for your family’s needs.
Some adjusters will pounce on this fear and offer a lowball settlement offer.
The lowballing technique means offering you an unreasonable amount for your losses.
Although this money may tempt you, evaluate whether it is a fair offer for the long-term problems you may have from the accident.
Accepting the first workers comp settlement offer is often a mistake.
Adjuster Trick #8: Intimidation
The insurance adjuster may use intimidation techniques to persuade you to accept a lowball offer.
For example, the adjuster may give you a “take it or leave it” offer, implying you have no room to negotiate a better deal. Or the claim rep may give you a short time (hours or days) to respond before withdrawing the offer.
Other examples of intimidation when negotiating a settlement include the following:
- If you are an undocumented worker in the United States illegally, threatening to report your legal status or have you deported
- If you have not filed taxes in several years, threatening to report you to the Internal Revenue Service (IRS).
- Threatening to report you to the state police for insurance fraud
- Telling you that if you do not settle, the insurer will do everything it can to delay litigation and payment for years.
- Threatening to interview your family (including your spouse and children), friends, clergy, or employer and to tell those persons information you do not want disclosed.
Adjuster Trick #9: Delaying Payment to Create Financial Hardship and Force a Settlement
Insurance adjusters are supposed to send you agreement forms and start making weekly temporary total disability payments when it is evident that workers comp covers your injury.
But that only sometimes happens.
Adjusters know your family depends on these workers comp checks when you cannot work. But unfortunately, some adjusters will use this against you and delay making payments to force you to accept a low settlement offer when you’re desperate.
This delay tactic works because adjusters know the Industrial Commission is unlikely to sanction them if they argue that they held you to your burden of proof. This allows them to wait until the Commission enters an Award Order to start paying you – a process that can take weeks or months.
Adjuster Trick #10: Sending You an Inaccurate or Incomplete Award Agreement Form
Often injured employees call me after the insurance adjuster has sent an agreement form for their signature.
In about 75% of these cases, the agreement form is incorrect – to the employee’s detriment.
The worst offenses are:
- Not listing every body part injured in the accident.
- Using an average weekly wage that is too low;
- Not providing wage loss benefits for the entire period the injured employee was out of work.
Do not sign an agreement form to make the adjuster happy.
The award must list the proper average weekly wage. Otherwise, you may receive lower payments for your entire claim due to the legal hurdles to amending this figure.
In addition, the form must list all the body parts injured and related conditions if you are outside the statute of limitations.
However, if you are within the statute of limitations, you can amend the Award Agreement in the future without the doctrine of res judicata barring you.
Adjuster Trick #11: Failing to Make Wage Loss Payments On Time
Even when the Commission has entered an award order providing you with wage loss benefits, the adjuster may start making late payments.
You can ask the Commission to penalize the insurance company if your wage loss check is late. But the Commission will only punish the insurance company if your work comp check is 14 days late.
The late check penalty is equal to 20 percent of the amount owed.
This tactic causes frustration, with the adjuster hoping you will accept a low settlement offer.
Adjuster Trick #12: Hiring a Private Investigator or Referring Your Claim to the Special Investigations Unit (SIU)
The claims adjuster may hire a private investigator or refer your claim to the insurance company’s Special Investigations Unit.
These investigators will follow you and take pictures or video footage, hoping you do something that seems above and beyond your work restrictions. The adjuster may then show the footage to your doctor or the Workers Compensation Commission if it shows that you are not as disabled as alleged.
The adjuster may also threaten to make a complaint with the Virginia State Police (or a similar agency in your state), even with no fraud. They hope that the threat of seeking criminal prosecution will encourage you to accept a low settlement offer.
Do not be intimidated. Your attorney can use discovery and cross-examination to determine if the video footage is edited. For example, for every 10 minutes of surveillance showing you performing physical activities, ten hours of footage may demonstrate you in pain or inactive from occupational injuries.
Most workers comp judges understand that the ability to do a physical activity for a few minutes does not mean you are capable of returning to full-duty work or that you are committing fraud.
Adjuster Trick #13: Paying Benefits Voluntarily to Run Out the Statute of Limitations
Each state has a deadline for filing a claim for benefits for a work accident.
For example, you have two years from the accident date in Virginia to submit a formal claim to the Workers Compensation Commission.
Some insurance companies will make voluntary payments, hoping to lull you into a false sense of security where you don’t file a formal claim. Then, when the statute of limitations expires, the insurer will stop making payments.
Often you only have an option if you submit a timely claim. That is why protecting your rights and following the procedural rules is essential, even when the insurance company appears to be looking out for you.
Adjuster Trick #14: Telling You That Your Case is Closed
I am stunned by the number of injured employees who call me and say the adjuster told them their case is closed. Usually, this is nothing more than a technique to get you to stop pursuing your case.
Few workers compensation cases are permanently closed. Indeed, the only claims that are closed for good are those where:
(1) Waited too long to file a claim and no exceptions to the statute of limitations apply.
(2) You settled your case, with the Commission entering an Order approving the settlement terms and closing your claim.
(3) You lost your case at the hearing and have exhausted all workers comp appeals.
You can “reopen your case” and pursue benefits if your situation does not fall within one of these scenarios.
Adjuster Trick #15: Constant Requests for More Information
You may feel like you are playing “whack-a-mole” because whenever you give the claim adjuster the requested information, they ask you to get or complete more paperwork. It seems some workers comp adjusters never have enough to make payments or authorize medical care.
For example, if you send reports from your doctor’s visit, the adjuster asks for a copy of the bill.
Or if you give the adjuster a referral to a specialist or for a second opinion, the adjuster asks for the underlying appointment note.
Or if you submit proof that you have medical work restrictions, the adjuster will want to wait until the next visit to offer an agreement form or to make a settlement offer.
No matter what you send, more is needed. The adjuster will always ask for more information.
Move forward with your case and refuse to remove your claim from the hearing docket if the adjuster constantly gives you the run around.
Adjuster Trick #16: Offering a Light-Duty Job that You Are Overqualified For
Your doctor may release you to light-duty work.
Under most workers comp laws, the adjuster can start vocational rehabilitation to find a job within these restrictions. And if you refuse the job, the adjuster can stop your workers comp benefits.
Therefore, some adjusters will find light-duty jobs you do not want to work in or with schedules that do not fit your family’s needs. Their hope is that the inconvenience will persuade you to give up your claim or settle it cheaply.
Adjuster Trick #17: Providing Light-Duty Work that Exceeds Your Restrictions
Some employers and adjusters offer jobs with the promise that you will not have to exceed your work restrictions.
Then, when you start working, your supervisor asks you to do more than you should, according to your doctor.
This request puts you in a difficult position of pushing yourself too hard to avoid litigation over whether your job refusal (if you quit) is justified.
Adjuster Trick #18: Denying the Claim Due to Pre-existing Conditions
Workers comp adjusters love to defend claims on the basis that ongoing disability and medical care are related to past injuries or diagnosed conditions.
Often this defense is easy to overcome, mainly if you went a long period without needing treatment or have been working full-duty for a year or more.
But it causes delay and increases litigation expenses if you need expert witness testimony from a doctor.
Adjuster Trick #19: Scheduling a Defense Medical Examination
The law permits insurers to send claimants for one-time defense medical examinations.
These exams, also called independent medical examinations (IMEs), are anything but.
The insurer hand-picks the doctor, and most of these reports result in unfavorable evidence for the claimant.
Then the claim adjuster uses this evidence to dispute your claim.
Click here for more information on what to expect from a workers comp IME.
Adjuster Trick #20: Stonewalling
The insurance adjuster may recommend pre-lawsuit mediation but show up with little settlement authority at the mediation conference.
Or the claim representative may wait until the week or day of trial to offer a reasonable settlement, causing you and your attorney to incur litigation costs.
Adjuster Trick #21: Fails to Conduct a Complete Investigation or Consider Evidence that You Provide
The claim representative may fail to thoroughly investigate your claim or give weight to evidence (such as doctor disability letters) you provide.
Therefore, the offer is based on incomplete facts and is unlikely to represent your losses.
Adjuster Trick #22: Unreasonable Delay
Some insurance adjusters will try to wait you out, taking months or even years to decide whether to affirm insurance coverage for the loss or pay a claim. Their goal is to get you to run out of patience and accept whatever settlement offer is on the table to get closure.
Sometimes this delay is unintentional. Instead, the adjuster needs better organizational skills or is waiting on a supervisor (claims manager) to respond.
We Will Handle the Workers Comp Adjuster While You Focus on Your Recovery
The claims adjuster will have a central role in your case. And most have experience, having handled hundreds of workers comp claims, attended numerous seminars on the law, and received advice from teams of defense attorneys.
The more you know about their tactics, their games, and what information they are looking for, the greater the likelihood you can settle your claim through direct negotiation or at a workers comp mediation.
You can teach yourself while trying to regain your health and make ends meet financially.
Or you can hire a top-rated work injury lawyer to take care of it for you.
Call me today for a free consultation: (804) 251-1620 or (757) 810-5614. Let my firm prosecute your claim.
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