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Thread Title: Adjuster is wrong
Created On Monday November 17, 2008 3:30 PM

feelin it
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Monday November 17, 2008 3:30 PM

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I just spoke with my atty. office and the new adjuster on my case keeps telling them every time they call this story about how all injured workers are frauds and so on .

Is this normal practice my old adjuster didn't do this and this is far from true ,scif is the insurance and I would love to hear what the true stats are on this subject, ie 10 % injured 90% insurance?

DoubleCrush
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Monday November 17, 2008 8:30 PM

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I can't put my finger on a recent article, but I do remember reading that fraud by the IW's is less than 2%, and also the lowest in dollar value. So the other 98% comes from either the employer, the medical field, or the insurers. I hope you get a better answer than this.

I think IW's are all looked upon as fradulent by a good percentage of the population. They here all about the fraud in the media, but don't realize where it's coming from. And, it just irks me when I read about an IW being arrested for fraud. Those are the cases that get the most publicity.

Any C/A, or any other person working in the WC system can "think" whatever they want, but when they verbally express their true feelings in a negative way towards IW's, they should be fired! I think your C/A's supervisor would want to know about this employee.

DC

gaiassoul1@yahoo.com
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Monday November 17, 2008 9:42 PM

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Not all adjusters are this way but there are people who use this as a tactic. They will find their own karma.

The correct response from your attorney's office is basically "put up or shut up"

They should be asking what false statement(s) you made to secure benefits. Dollars to donuts, they have nothing that would stand in court. So once an attorney establishes they won't be pushed around that should pretty much silence the alleged fraud topic.

It is too bad there are so few professionals in the claims examining end anymore.

Personally, when most adjusters scream fraud, they generally have no clue what they are talking about, it is not usually fraud but rather a debate as to the injured workers level of malingering of which there can be some, but it is not all intentional....if they gave the medical care that the injured worker was entitled to in the first place, we would not see the "pain" behaviors develop and continue longer then need be in most situations.

my .02 for the day....getting down off the pedestal.

-------------------------
Ginger

To know how to say what others only know how to think is what makes men poets or sages; and to dare to say what others only dare to think makes men martyrs or
reformers - or both. Elizabeth Charles

steve appell
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Tuesday November 18, 2008 9:10 AM

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"Put up or shut up" & "under 2%" is also the way I see it.

It is a statistical fact that vendors, docs and ER's year in & year out cause considerably more fraud than IW's. Also, the "F" word should NEVER NEVER be spoken by any party unless it can be proved. This of course requires a "Material Misrepresentation" and not simply exaggeration or Malingering.

Good Luck!

-------------------------
Steve

Edited: Tuesday November 18, 2008 at 9:44 AM by steve appell

postscript2
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Tuesday November 18, 2008 1:34 PM

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I've posted this before and I'll post it again, there has to be "INTENT" before the "f" word is used, and PROOF to back it up. Prosecutions are "rare," but they do happen.

Most TPA's and I/C's are required to meet a certain # of referrals/quota for suspected fraud per month. I've seen some of the most ridiculous FD-1 filings ever, just because someone didn't pick up their phone or missed a doctor's appt. I believe these become part of a national data base, just as the Index Bureau for filed injuries.

I would also agree on the 2% level by my own experience.

"Malingering" is the I/C-Legal term for exagerrating symptoms, absent pathology. Some folks, not just I/W's are more prone to pain tolerance than others. No two claims or individuals will ever be alike.

As the older/more experienced C/A's retire, win the lottery or for what ever reason, move on to greener pastures, they are being replaced by younger, less estute C/A's with classroom education only.

--AND as well all know, myself included, reading of the statutes and case law, if misinterpreted can lead to some bad claims handling. At any rate no one should be crying wolf without proof that the sheep are missing!

LCS

steve appell
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Tuesday December 02, 2008 11:55 AM

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Check today's WCC article titled "Staffing Firm Execs Accused of $18M Premium Fraud" for another example of ER fraud.

-------------------------
Steve

Backouttawack
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Wednesday December 03, 2008 11:28 AM

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My adjuster also used the "f-word" on the phone with my atty while I was sitting in his office right in front of him. This was even after she had recieved MRI reports and their Drs. recommendation for spine surgery on a major disc herniation with nerve compression. I have also been in my Ortho's office and overheard one of his nurses basically having a screaming match with my IA over the fact that I needed to be seen by another particular specialists ASAP and the IA couldn't understand why and was refusing treatment. Ahhhh, fun times. I pray you don't have my adjuster or there are not more of them out there. LOL!

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