Dealing with the Workers’ Comp Adjuster in Virginia: The Tactics, What to Say, and When to Get Help

Corey R. PollardWorkers’ compensation attorney · Former insurance defense · $100M+ recovered

The adjuster handles your claim for your employer or its insurer, not for you. Answer accurately, keep dated notes, put important requests in writing, follow up each phone call with an email memorializing what you discussed, and don’t give a recorded statement or sign anything until you’ve talked to a lawyer. If you already have a lawyer, let them handle the conversations with the adjuster.

Before I represented injured workers, I defended employers and insurance companies. I’ve read a lot of adjuster files and claim notes from both sides. Most adjusters aren’t bad people; they are overworked employees following guidelines meant to keep costs down. But those guidelines, and some adjuster habits, cost injured workers real money and a healthy future if they don’t know what’s happening.

If the adjuster sent you an employer’s application to stop or reduce your benefits, that’s a Workers’ Compensation Commission filing with its own deadlines and rules. Learn about that procedure on my page that explains how to respond to an employer’s application that stops benefits. This page is about the ordinary contact with the adjuster.

Who does the adjuster work for, and what can they decide?

The adjuster may work for your employer’s insurance carrier, for a claims administrator such as Sedgwick or Gallagher Bassett, or for a self-insured employer’s own claims department. Either way, the adjuster answers to whoever pays the workers’ compensation benefits, not to you. If you have received letters or emails from Sedgwick, read my page on what to expect when Sedgwick handles your claim. Their job is to investigate, decide what the carrier will pay and what medical treatment to authorize, and defend the insurer’s position if you disagree. Ultimately, a closed file is a good file for an adjuster.

What the adjuster decides is the insurance company’s position, not a Commission order. Under the Act, the Commission determines questions not settled by the parties’ agreements as approved by the Commission. An agreement about compensation binds only once it’s filed and approved by the Commission, which then enters an award (§ 65.2-701(A)). So the words “accepted,” “denied,” or “closed” tell you what the carrier is doing. They don’t tell you which injuries and benefits are covered, whether you have an award, or what you still need to file.

One other phrase you may hear from the adjuster: “not accepted yet.” After you file a claim, the Commission requires the employer to take one of three positions: it accepts the claim in whole or in part, it denies the claim and gives a reason, or it states it cannot decide yet and needs to continue investigating. (§ 65.2-601.2(A)).

That last position – still investigating – often gets lost in translation. Here is an example of how: A doctor’s office calls the adjuster to schedule a follow-up appointment for your work injury, hears the claim “hasn’t been accepted yet,” and tells the patient (you) it was denied. But nothing was denied. When anyone other than the adjuster tells you the insurance company’s position, confirm it, and ask whether the claim is accepted, denied, or under review.

How the carrier estimates what your claim will cost is on my page about workers’ comp claim reserves. What to consider when deciding what your claim is worth is on my workers’ compensation settlements page.

What should I do when the adjuster contacts me?

If you have a lawyer, let your lawyer direct communication with the adjuster, and ask which things, if any, you should handle yourself. The rest of this section is for workers handling the contact on their own.

Treat the first contact as the start of a continuous record, because for the employer and insurer, it is. Insurance carrier guidelines usually require the adjuster to contact you within a day or two of the reported injury and document your account of what happened. That speed is the adjuster’s instruction – what their boss evaluates them on – not your obligation.

• Identify the caller. Get their name, company, whether they represent the employer or its insurer, the claim number, a direct phone number, and email.
• Have the basics ready. Know the accident date and place, what you were doing when you got hurt or first felt pain, any witnesses, who you reported the injury to, where you have received medical care, and your current work restrictions.
• Answer accurately. Don’t guess at dates, downplay your symptoms to seem “tough” or cooperative, or exaggerate. It’s ok to answer “I’m not sure” or “I have to check.”
• Ask when a question is unclear. Adjusters use shorthand like “mechanism of injury,” “prior claims,” and “MMI.” Ask what it means before you answer.
• Confirm important things in writing. After a call where you were asked for something or told that something matters, send a short email: “As we discussed today, you asked for X, and you told me Y.”
• Read before you sign. A blank medical authorization form can reach far beyond your claim, and an agreement form sets the terms of your award order, which is the most important document in your case. My pages on medical records releases and award agreements cover what to check.

Three things people confuse:

1. Notice to your employer. This is your legal duty. You must provide written notice “immediately” after the accident happens or as soon as practical. (§ 65.2-600(A), (B)). The Act’s 30-day limit, with its exceptions (§ 65.2-600(D)), is the outer edge, not a grace period. See my page on reporting a work injury for the details.
2. The carrier’s claim file. This is the adjuster’s record. Opening it doesn’t protect your rights or toll the statute of limitations.
3. You must file a claim with the Commission. This document is yours. Your right to compensation is “forever barred” unless you file within two years of the accident. Some voluntary payments and employer failures can extend the deadline (§ 65.2-602), but don’t count on it. The adjuster working on your file does not protect it. My statute of limitations page explains the clocks.

Should I give the adjuster a recorded statement?

My advice: don’t give a recorded statement without talking to a lawyer first.

A recorded statement is an informal interview, usually by phone, where the adjuster asks about the work accident, your injuries, your medical history, your job, and your work status, and records their questions and your answers. The law does not require you to give a recorded statement to receive workers’ compensation benefits. Nor is a recorded statement the same as formal discovery allowed under the Workers’ Compensation Commission’s Rules. Depositions and written discovery (interrogatories, requests for production, etc.) come later, when your claim is pending.

Adjusters ask for a recorded statement because their company guidelines require it. For example, one Northern Virginia county seems to require its claims administrator to “obtain recorded verbal statements from the injured worker, and if applicable, any witnesses on all claims where compensability is questionable or if the claim was reported more than three (3) business days post-incident.” (Loudoun County RFQ 137782, §§ 5.1(C), (D)).

An employer’s or insurer’s internal policy does not bind you. The Act and the Commission’s Rules tell you what you must do to protect your rights: give notice (§ 65.2-600), file a claim (§ 65.2-601), attend a medical examination the employer arranges (§ 65.2-607(A)), and answer formal discovery once a claim is pending (Rule 1.8). An informal recorded interview with the adjuster is not on that list.

The danger usually isn’t trick questions from the adjuster. It’s the timing of the statement.

An early recorded statement, given before you know how badly you’re hurt, becomes the version the insurer measures every later statement from you or your doctor against. If you say that your back “feels fine” the day after a workplace fall, but your pain worsens over the next few days and an MRI three weeks later shows a herniated disc, you didn’t lie, but you did give the carrier a sentence it can read back to you and the deputy commissioner at a hearing.

Now, refusing to give one can have consequences, and you should know that. A carrier that says it cannot finish its investigation may decline to accept the claim until completing formal discovery or an evidentiary hearing, and it can take your testimony under oath later. That’s why you should make the decision whether to give a recorded statement with a lawyer who has reviewed your file and your case’s facts, not on an unexpected call from the adjuster.

If you get the adjuster’s call out of the blue, say you want to understand what the statement involves first, and ask the following questions:

• What is it for?
• Is it recorded?
• Can you have a copy of the recording after the call?
• What will the statement cover?
• Can you see the questions in writing first?

Once you have these answers, tell the adjuster you will reach out if you want to move forward with the recorded statement. Then get legal advice.

If you decide to give one, schedule it for a day and time that you have your notes and medical records in front of you. Answer only what the adjuster asks. If you don’t know the answer, say so. And if the adjuster asks for a fact that you can look up and verify later, say that you will have to look into it. Don’t worry so much about shaping the story at this point; the worst thing you can do is build a narrative that later testimony and reports don’t fit. Simply describe the accident as it happened, and correct yourself on the spot if you misspeak.

If you have already given one, ask for the transcript. Virginia law requires whoever took a recorded statement from an injured person to provide one on request. (§ 8.01-417(A)). Then review it with your lawyer. If the statement has a mistake, send a prompt written correction saying what was wrong and what is right, not a new version of events.  

On recording the call yourself: Virginia is a one-party consent state, which means it is lawful for a party to a conversation to record it. (§ 19.2-62(B)(2)). But the adjuster may be in a state with different rules, so check before you record, and let the adjuster know you will also record the call. Get confirmation from the adjuster in writing or on the recorded call.

Workers’ comp adjuster tactics I saw from the defense side and continue to see, and how to respond

Workers’ compensation adjusters use specific techniques to investigate, defend, and negotiate settlements.

These tactics are legal. But they still hurt claims when injured workers don’t recognize them.

They try to get to you before you know how hurt you are. Early contact with the injured party is built into carrier guidelines, and some adjusters push it hard, to the point of seeming aggressive. I’ve heard stories of adjusters calling an injured worker and asking questions while the worker is lying in the hospital bed after a catastrophic construction incident, hooked up to an IV and sedated on pain medication.

Your response: You don’t owe anyone a detailed account from a hospital bed or before talking to an attorney. Take their contact information and say you’ll follow up once you’ve had a chance to heal.

Discouraging you from hiring a lawyer. Part of my early investigation is asking the injured worker about conversations they have had with the adjuster. Many times, the worker tells me that the adjuster said things like, “A lawyer will slow this down,” or “You will get less money in your pocket if you have to pay an attorney’s fee.”

No lawyer, at least not any credible one, can guarantee a certain outcome. But many workers’ comp attorneys, including me, work on a contingency-fee basis. We get paid only if we recover benefits or negotiate a settlement for you. And if you have already received a settlement offer when you retain me, you only pay a fee if I’m able to negotiate a better outcome. There is no scenario where you will net less by hiring me.

Additionally, in Virginia, the Workers’ Compensation Commission must approve attorney’s fees in all cases (§ 65.2-714), so fees are reviewed for fairness. A lawyer also knows which filings create deadlines the carrier has to meet, which usually speeds things up.

Your response: Get a free consultation, then decide. The adjuster isn’t neutral on this issue.

The agreement form that’s close, but not quite right. Many of the proposed Award Agreement forms I review are mostly correct but leave out or incorrectly state an important fact. Sometimes the average weekly wage is too low, other times the form leaves out a body part entirely, or maybe the insurer agrees to a closed period of temporary total disability (TTD) instead of ongoing payments. A wage that’s too low and gets memorialized in an Award Order reduces the value of your claim, and fixing it later is more difficult than taking the time to get it right now.

Your response: Ask for a Wage Chart before you sign the form, then check that chart against your pay records and bank statements. You should also check every injured body part listed in the form against your medical reports and check the dates you were out of work. See my page on award agreements for a complete checklist.

Sending voluntary checks and covering medical treatment up to the two-year deadline. Some adjusters pay benefits, both wage-loss and medical, without an award in place, and unrepresented workers reasonably assume they’re covered. But they are not protected. If the insurance company stops paying after the two years under § 65.2-601 have run, you may lose your case on a statute-of-limitations defense.

Your response: File a written claim for benefits with the Commission even if your case is going smoothly and the insurer has covered all wage loss and medical treatment. It costs nothing.

Late checks. Once you have an award, the insurer should make regular payments on a schedule. But despite the adoption of automation and artificial intelligence, some adjusters make late payments. And the Workers’ Compensation Act gives them leeway, even though the bills you have to pay on time remain. The Act allows you to seek a 20 percent penalty for any check more than two weeks late (§ 65.2-524); however, the hassle that comes with these delays is an adjuster tactic to get you to accept less money to close your case.

Your response: Keep a log of when each check arrives, and seek penalties as soon as you are eligible to do so. Don’t let the insurer off the hook. Let it know that you will continue to fight for your rights and fair treatment.

Surveillance and fraud talk. Adjusters may mention referring your file for surveillance – or actually do so – if their system sees a “red flag,” you suffered a severe injury or earned a lot of money (both of which increase the potential claim costs), or simply to rattle you. Hours of surveillance footage are then edited into a few minutes of activity – carrying a small bag of groceries or standing up while getting out of the car – to prove you are exaggerating your symptoms when you talk to the doctor. Deputy commissioners generally understand that a few minutes of activity is not proof that you are faking the injury or symptoms. But adjusters know this cloud will hang over your head.

Your response: Follow your restrictions and watch what you post on social media. Insurers can hire private investigators to follow you or view your posts to gather evidence that you are not being truthful.

Light duty that doesn’t match your restrictions. An employer can file an application to stop benefits if you refuse to accept a job within your restrictions and the Commission finds that refusal is unjustified. (§ 65.2-510). Some offers look good on paper, but once you get to the office, your supervisor asks you to violate those restrictions. This puts you in a tough spot: exceed your restrictions and suffer further harm, or stop showing up and go without benefits for a time while the Commission decides if the job was within your restrictions and your refusal was justified.

Your response: Get the job description in writing and show it to your doctor. If you’re asked to go beyond your restrictions, document it the same day. See my page on light duty and work restrictions.

Why does the adjuster keep asking for more, or stop responding?

Much of what looks like pressure or silence comes from how adjusters’ supervisors measure them and how many files they carry. Adjusters get evaluated on how fast they reach out to injured workers, documentation, completing file reviews on time, how long claims stay open, and how much is paid. None of these involves a legal duty owed to you, but each suggests a next step.

The investigation. The adjuster has to document the accident quickly because the decision to accept compensability or deny the claim rests on that record. Next step: give accurate facts and ask exactly what else the adjuster needs to start paying benefits.

Documentation and approval: Authority to pay benefits, authorize treatment, or settle above a threshold comes in layers. An adjuster’s supervisor won’t sign off on the next level unless the file supports the adjuster’s request. You can speed up this step by asking what document is delaying things, then sending in a copy.

Scheduled file reviews. Adjusters work files on a diary and a set review date, commonly every 30 to 90 days. That’s also when the adjuster reviews the claim reserve and updates it. Next step: ask when the adjuster can review your file again and send new medical reports and restrictions to them before then.

Workload and silence. Adjusters carry a lot of open files – sometimes several hundred. So the lack of a response may be an overworked adjuster, rather than someone intentionally ignoring you. Regardless, the effect on your health and finances is the same.

When I get the adjuster’s claim notes in discovery, they often show that the worker had to leave several voicemails and emails before anyone called back or authorized treatment. For example, in a case a few years ago, my client, who needed ankle surgery after a work accident and had an award order, asked for a new adjuster because her current one took so long to get back to her, and she was concerned that delaying surgery further would affect her ability to walk. Next step: each time you email or write to the adjuster, put the date of your last contact, ask for a written status, and then ask for the supervisor’s name.

You can also force a deadline: Once you file a claim, the Commission orders the employer to state within 30 days whether it accepts, denies with reasons, or needs more information. That deadline runs from the Commission’s order, not your first phone call.

If your problem is waiting on approval for treatment, my page on medical treatment denials explains the Petition for Medical Treatment.

What do common adjuster phrases mean?

Two things adjusters do that belong on other pages: an examination the employer arranges under § 65.2-607 is explained on my IME page, and how insurers gather evidence about you outside the file, including through investigators and your own posts, is on my page about social media and your claim.

When is another phone call not enough?

Some communications need a lawyer’s eyes before you respond.

• A threatened or actual cutoff. An employer’s application to stop or change benefits is a Commission filing under Rule 1.4, with its own deadlines for objections. See why your benefits stopped covers it.
• A denial, whether of the whole claim or part of it. Ask for the reasons in writing, then see my page on denied claims.
• Disputed work restrictions. This includes an offer your doctor’s note doesn’t support, or an adjuster claiming you’re released when your doctor says you aren’t. My page on light duty and doctor restrictions explains what to do.
• Pressure to sign an agreement form, a medical authorization, or anything else with a signature line and a deadline.
• Explanations that keep changing. The reason for a delay or denial changes from one call to the next.
• Anything from the Commission. Orders, hearing notices, and applications often have deadlines that don’t wait for the adjuster to call back.

Tell me what the adjuster said

Send me the adjuster’s name and company, your claim number, and the last three things you were told or asked for, in the adjuster’s words if you have them. If we accept representation, I’ll tell you what the carrier is likely doing with your claim, what needs a response, and what that response should say. Start your free case review or call Richmond at (804) 251-1620 or Hampton Roads at (757) 810-5614.

Keep reading

• Virginia Workers’ Compensation Guide: What You Should Know
• Why Did My Workers Compensation Benefits Stop?
• Medical Treatment Denials in Virginia Workers’ Compensation

About the authorCorey Pollard is a Virginia workers’ compensation and Social Security Disability attorney in Richmond. Best Lawyers in America® (2020–2026), $100M+ recovered, and a former insurance defense lawyer — which is the part that matters.