NHRMA Mutual

Claims Decisions Requiring Member Involvement

Is the case going to be handled as compensable claim?

If a claim isn't clearly compensable or non-compensable, the adjuster will contact the member with a summary of the claim details, along with an option to accept or deny the claim. The adjuster will offer their expertise and recommendations.

Should an Independent Medical Evaluation be performed?

If an employee has been treating for an extended period of time, or if a surgical procedure is recommended, the adjuster may want to schedule an independent medical examination or second opinion examination. The adjuster will contact the member and explain the need for the examination.

Should case management be assigned?

A case manager acts as a liaison between the claimant, employer, adjuster and medical provider. Case management can be assigned on a full or limited basis. Before it is assigned, the adjuster will contact the member and explain the necessity for this service.

Should surveillance be assigned?

This is normally the most expensive option of claim handling. The adjuster will contact the member to determine if there may be a reason for surveillance.

Should this employee be considered for an early return to work program?

When an employee is released to return to work on a limited basis, the adjuster will contact the member to determine if this is a viable option.

Should the case be referred to a defense attorney for handling?

Sometimes a case reaches an area of expertise that an adjuster cannot manage without legal assistance. A case must be referred when the claimant's attorney files a motion for hearing and intention to proceed to trial. However, most cases can be concluded by the adjuster without the expense of litigation and attorney's fees. Before any case is referred for defense activity, the member will be consulted.

Should benefits be terminated?

If the adjuster finds that there are grounds for benefit termination, he will contact the member to discuss those options prior to making a final decision.

Should we make a settlement offer? Amount? Stipulations? Appeal after trial?

Prior to making a settlement offer of any type, the adjuster will contact the member and explain the settlement options.

Likewise, all activities that arise from these should be discussed with the employer. (For example: IME results, surveillance results, defense attorney's opinion of case, case management reports, settlement negotiation status.)