Taking Ownership of Your Claims

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By Cheryl Riley, Director of WC Claims & Fred Tucker, Vice President of Liability Claims – PGCS Claim Services

As a Preferred Member, you play a very important role in the outcome of a claim. When a Member takes ownership of their claims and plays an active role in the claims process, it is a better experience for all involved. 

Timely claims reporting is the most important action for the Member and can set the tone for the entire process. Often the Member is the first to know when a claim occurs. This triggers the start of the fact gathering process.

Thorough investigation can make or break the process, so timely reporting is essential for a member who wants to positively impact the claims process.

In the event of a Workers’ Compensation injury claim there are several factors that come into play. Timely reporting allows the adjuster to assist in authorizing appropriate, timely medical attention to help reduce the severity of the injury.

In addition, timely reporting allows the Claims Adjuster to investigate and commence payment of benefits, if due and owing, to your employee in a timely manner while maintaining control of the claim.

Some pertinent items a Member will take an active role in providing for the adjuster include:

  • A detailed description of the accident to include any witnesses.
  • A modification of job duties for the injured employee as they recover. An effective Light Duty Policy can reduce employee time away from work and reduce claims costs.
  • For motor vehicle accidents the adjuster will be investigating for subrogation recovery potential and will need to know who was the at fault party.

In regard to Liability claims (i.e. automobile and general liability), open communication between the Member and PGCS adjuster at the onset of the claim is essential for gathering facts and completing a thorough investigation.

Fresh information is important and any delay in reporting may result in facts becoming murky.

In addition to timely reporting, a Member can positively impact the claims process in the following ways:

  • The Member should make an effort to provide as much supporting documentation as possible (i.e. police reports, Supervisor’s Accident / Injury Investigation Report, Employee’s Accident / Injury Statement and Vehicle Accident Report) as it will allow the adjuster to complete a timely investigation. The goal is to minimize the substantial time and expense that always goes with claims in litigation.
  • Throughout the course of a claim, a number of events may occur. Remember to openly communicate with the adjuster to help mitigate and conclude the claims investigation.

Taking an active role in the Claims Review process is crucial for Members. These reviews are meant to provide a structured, yet open, dialogue regarding claims. Though they are hosted by and provided to the Member by PGCS, the Member’s input is vital. These reviews typically focus on losses that have a specific characteristic such as incurred amount, litigation status, type of Coverage, etc.

The selection of claims for review is done jointly with the Member and allows for a productive discussion of individual claim strategies to support the Member’s safety programming and risk management initiatives. In addition, Claims Reviews provide the Member, Loss Control and the PGCS adjuster the ability to identify trends as they relate to injuries or accidents. Claims Reviews allow the member to take measures to avoid accidents and injuries in the future.

In support of this it is important to have your Preferred Regional Loss Control Consultant included in your Claims Reviews. This will assist in helping you identify the root cause of the claim as well as what recommendation(s) should be made to prevent reoccurrence. Loss Control can work with the appropriate departments to recommend subsequent remedial measures to ensure the area affected is safe, work methods are improved, and defective tools removed from service until appropriate corrective action can be provided.

Actively tracking claims by use of the PGCS website provides a means to track and trend claim frequency /severity. This allows the Member to identify the top loss drivers, by line of coverage, that are having the most deleterious effect on the performance of the Member’s insurance program and provide corrective action as may be required. The PGCS Claims Database member portal provides access to reporting resources, access to financial information and the ability to review adjuster claim notes.

In summary, there are several effective ways for the Member to positively impact the claims process by providing for the timely reporting of claims, having ongoing open communication with the adjuster, taking an active role in Claims Reviews and utilizing the tools available via the PGCS website. Remember our moto… “Claims, They Can Make or Break You”.

Cheryl Riley, Director of WC Claims

Cheryl is responsible for the overall management of the workers’ compensation team at PGCS. Cheryl began her career in the insurance industry with CNA in 1984. After joining United Self Insured Services in 2002, Cheryl transferred to PGCS in 2007. While at PGCS she has held the positions of Account Manager, Quality Assurance Manager and Workers’ Compensation Claim Manager prior to her current position of Director of WC Claims. Cheryl holds a Florida all lines claims adjuster license. Cheryl has also earned the designation of a Board Certified Workers’ Compensation Litigation Adjuster.

Fred Tucker, Liability Claims Manager

Fred is Vice President of Liability Claims for PGCS with their area of focus on Municipalities and Governmental Entities throughout the State of Florida with expertise in Automobile Liability, General Liability, First Party Property including Hurricane and Catastrophic Losses, Professional Liability, School Leaders/Educators Liability, Employment Practices Liability, Public Officials Liability and Law Enforcement Liability