Workers Comp Adjuster - FAQ

Workers Comp Adjuster — FAQ

Read­ing Time: 5 min­utes

Last Updat­ed on June 19, 2023 

Insur­ance Com­pa­ny Adjuster Ques­tions? Get Legal Help! Call Now for a FREE Con­sult with an Expe­ri­enced Work­ers Comp Lawyer at 844–682‑0999.

What Are 20 Common Questions You May be Asked in a Recorded Statement by Workers Comp Adjuster? 

  1. How did your injury occur?
  2. Describe the inci­dent in detail.
  3. What med­ical treat­ment have you received for your injury?
  4. How has your injury affect­ed your abil­i­ty to work?
  5. When did you first become aware of your injury or the onset of symptoms?
  6. Did you report the inci­dent to your employer?
  7. Are you cur­rent­ly tak­ing any med­ica­tions for your injury?
  8. What restric­tions have you been told to fol­low by your physician?
  9. Have your med­ical bills been paid by your employer?
  10. Have you received any oth­er ben­e­fits from your employ­er in con­nec­tion with this injury?
  11. How much time have you missed from work due to your injury?
  12. Have you been released to return to work?
  13. Are you cur­rent­ly receiv­ing work­ers’ com­pen­sa­tion benefits?
  14. Are you aware of any oth­er poten­tial sources of recov­ery for your injury?
  15. Are you rep­re­sent­ed by an attorney?
  16. Do you have any wit­ness­es that can cor­rob­o­rate your ver­sion of the incident?
  17. Have you been able to per­form your job duties since the incident?
  18. Are you able to per­form the same duties as pri­or to the incident?
  19. Are you able to per­form any work at all?
  20. Have you been able to return to any oth­er type of work since the injury?

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What are Top 20 Reasons Why A Workers Comp Claim is Denied? 

1. Inac­cu­rate or incom­plete infor­ma­tion. If the infor­ma­tion pro­vid­ed on the claim is inac­cu­rate or incom­plete, the claim may be denied. 

2. Fail­ure to fol­low instruc­tions. If the claimant does not fol­low the instruc­tions for fil­ing a claim, the claim may be denied. 

3. Lack of med­ical evi­dence. If there is insuf­fi­cient med­ical evi­dence to sup­port the claim, the claim may be denied. 

4. Fail­ure to meet dead­lines. If the claimant does not meet the dead­lines for fil­ing the claim, the claim may be denied. 

5. No con­nec­tion between the injury and the employ­er. If there is no con­nec­tion between the injury and the claiman­t’s employ­ment, the claim may be denied. 

6. Lack of proof of injury. If the claimant can­not pro­vide proof of injury, the claim may be denied. 

7. Fraud or mis­rep­re­sen­ta­tion. If the claimant com­mits fraud or pro­vides false or mis­lead­ing infor­ma­tion, the claim may be denied. 

8. Pre-exist­ing con­di­tions. If the claimant has a pre-exist­ing con­di­tion that con­tributed to the injury, the claim may be denied. 

9. Fail­ure to seek med­ical treat­ment. If the claimant does not seek med­ical treat­ment for the injury, the claim may be denied. 

10. Inel­i­gi­bil­i­ty for ben­e­fits. If the claimant is not eli­gi­ble for work­ers’ com­pen­sa­tion ben­e­fits, the claim may be denied. 

11. Fail­ure to report the injury. If the claimant does not report the injury in a time­ly man­ner, the claim may be denied. 

12. Injury is not work-relat­ed. If the injury is not work-relat­ed, the claim may be denied. 

13. Mis­clas­si­fi­ca­tion of the employ­ee. If the employ­ee is mis­clas­si­fied as an inde­pen­dent con­trac­tor, the claim may be denied. 

14. Occu­pa­tion­al dis­ease or ill­ness. If the injury is an occu­pa­tion­al dis­ease or ill­ness, the claim may be denied. 

15. Insuf­fi­cient med­ical evi­dence. If there is insuf­fi­cient med­ical evi­dence to sup­port the claim, the claim may be denied. 16. Injured work­er is not cov­ered by work­ers’ com­pen­sa­tion. If the injured work­er is not cov­ered by work­ers’ com­pen­sa­tion insur­ance, the claim may be denied. 

17. The injury occurred out­side of work hours. If the injury occurred out­side of work hours, the claim may be denied. 

18. Injury is not seri­ous enough to qual­i­fy for ben­e­fits. If the injury is not seri­ous enough to qual­i­fy for ben­e­fits, the claim may be denied. 

19. Fail­ure to pro­vide the required doc­u­ments. If the claimant fails to pro­vide the required doc­u­ments, the claim may be denied. 

20. Fail­ure to coop­er­ate with the inves­ti­ga­tion. If the claimant fails to coop­er­ate with the inves­ti­ga­tion, the claim may be denied.

How to Answer Workers Comp Insurance Adjuster’s Questions? 

1. Answer all ques­tions hon­est­ly and accu­rate­ly. The work­ers’ com­pen­sa­tion adjuster is respon­si­ble for assess­ing the claim and deter­min­ing the amount of ben­e­fits due. It is impor­tant to answer all ques­tions hon­est­ly and accu­rate­ly to ensure a fair and accu­rate assess­ment of your claim. 

2. Pro­vide all rel­e­vant infor­ma­tion. If request­ed, pro­vide the adjuster with all rel­e­vant infor­ma­tion, such as med­ical records, wit­ness state­ments, and any oth­er doc­u­ments that are per­ti­nent to the claim. 

3. Ask ques­tions. If the adjuster is ask­ing ques­tions that you don’t under­stand, don’t be afraid to ask for clarification. 

4. Remain polite and pro­fes­sion­al. While it is under­stand­able to be frus­trat­ed with the process, it is impor­tant to remain polite and pro­fes­sion­al when com­mu­ni­cat­ing with the adjuster.

What not to say to a workers’ comp claims adjuster? 

1. Do not make false or exag­ger­at­ed state­ments. Do not make false or exag­ger­at­ed state­ments when speak­ing with the adjuster – this could be con­sid­ered fraud and could result in a denial of the claim. 

2. Do not make assump­tions. Do not make assump­tions about the claims process or the adjuster’s intentions. 

3. Do not become hos­tile or aggres­sive. Do not become hos­tile or aggres­sive when com­mu­ni­cat­ing with the adjuster. This could be seen as unco­op­er­a­tive and may neg­a­tive­ly impact the out­come of the claim.

4. Do not make threats. Do not make threats of legal action or oth­er con­se­quences if the adjuster does not act in your favor. 

5. Do not dis­cuss the claim in pub­lic. Do not dis­cuss the details of the claim in pub­lic. This could be seen as an attempt to influ­ence the out­come of the claim.

How do you negotiate with a workers’ comp claims adjuster? 

1. Under­stand the claims process. Before attempt­ing to nego­ti­ate with a work­ers’ com­pen­sa­tion adjuster, it is impor­tant to under­stand the claims process and the adjuster’s role in it. 

2. Gath­er evi­dence. Gath­er all rel­e­vant evi­dence, includ­ing med­ical records, wit­ness state­ments, and oth­er doc­u­ments relat­ed to the claim, to sup­port your position. 

3. Make a rea­son­able offer. Make a rea­son­able offer that takes into account the cir­cum­stances of the claim. 

4. Remain polite and pro­fes­sion­al. Remain polite and pro­fes­sion­al when com­mu­ni­cat­ing with the adjuster. 

5. Be pre­pared to make com­pro­mis­es. Be pre­pared to make com­pro­mis­es on cer­tain aspects of the claim in order to reach an agreement. 

6. Fol­low up. Fol­low up with the adjuster as need­ed to ensure that the claim is pro­gress­ing in a time­ly manner.

What are 10 factors Workers Comp claims adjusters consider to determine settlement value? 

1. Assess the claim. The work­ers’ com­pen­sa­tion adjuster will assess the claim to deter­mine the sever­i­ty of the injury or ill­ness and the amount of com­pen­sa­tion due. 

2. Con­sid­er the expens­es. The adjuster will con­sid­er the amount of med­ical expens­es, lost wages, and oth­er costs asso­ci­at­ed with the claim. 

3. Deter­mine the sever­i­ty of the injury. The adjuster will con­sid­er the long-term effects of the injury and any per­ma­nent impair­ment that may result from it. 

4. Assess the risk of lit­i­ga­tion. The adjuster will assess the risk of lit­i­ga­tion if the claim is not settled. 

5. Con­sid­er state laws. The adjuster will take into account any rel­e­vant state laws that may affect the amount of the settlement. 

6. Eval­u­ate the claimant’s cred­i­bil­i­ty. The adjuster will eval­u­ate the claimant’s cred­i­bil­i­ty to ensure that the claim is valid. 

7. Con­sid­er pri­or set­tle­ments. The adjuster will con­sid­er pri­or set­tle­ments for sim­i­lar claims to deter­mine how much the set­tle­ment should be. 

8. Review med­ical evi­dence. The adjuster will review med­ical evi­dence to assess the sever­i­ty of the injury and the amount of com­pen­sa­tion due. 

9. Con­sid­er the claimant’s age. The adjuster will con­sid­er the claimant’s age and how long the injury may affect their future earnings. 

10. Take into account the claimant’s lifestyle. The adjuster will take into account the claimant’s lifestyle and how it may be impact­ed by the injury.

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