Accident Investigation and Aggressive Claims Management Leads to Positive Outcome from the NC Industrial Commission

Synergy Coverage Solutions is committed to providing extensive loss prevention services and aggressive claims management.  The workers’ compensation industry is surrounded by exaggerated and fraudulent claims; therefore it is of utmost importance for an employer to have an accident investigation program in place and conduct an accident investigation immediately following any alleged injury (accident investigations also offers insight so a similar or more disastrous accident may be prevented).  In the same way the employer conducts the accident investigation, the workers’ compensation service provider must begin a thorough claims investigation to research and piece together all details of the claim.

A recent claim handled by Synergy Coverage Solutions demonstrates the importance of timely accident investigation and aggressive claims management, resulting in a positive ruling for Synergy Coverage Solutions and the employer by the North Carolina Industrial Commission.  In summary, the claimant was working when she was unable to exit a room due to a door jam.  She was eventually instructed by the custodian to exit via the first floor room window, 40 inches from the ground, and use a ladder on the outside of the building to reach the ground.  The claimant contends she suffered neck and low back pain from climbing out of the window and lowering herself onto the ladder on the outside of the building.

Typically, the NC Industrial Commission is favorable towards neck and back claims.  However, in this case, Synergy’s aggressive and diligent claims investigation lead us to the decision to challenge the way the commission typically rules, based on the detailed facts gathered in the investigation.  After reviewing medical records from the claimant’s doctor (who had performed surgery from a prior incident involving a neck injury), and reviewing the employer’s accident investigation information, the Claims Adjuster denied the claim based on the conclusion that the pain and treatment received was not a direct or natural result of, or causally related to the incident.  The North Carolina Industrial Commission concurred with Synergy’s decision and upheld the denial.  The Commissioner’s opinion indicated that to be compensable, an injury “must result from an accident, which is considered as a separate event preceding and causing the injury; the mere fact of injury does not of itself establish the fact of accident.” 

Working with the employer, Synergy took a decisive, yet fair, stance after gathering all the details regarding the incident.  The employer’s ability to complete a thorough and timely accident investigation helped build a strong representation of the incident.  The employer was able to identify and gather detailed statements from witnesses in a timely manner, so the details from the incident were not lost, but easily recalled.  A tool that our competitors don’t typically use is obtaining information on past medical treatment.  Synergy Claims Adjusters are trained to think creatively, and out-of-the-box, to gather details that paint a clearer picture of the alleged injury.  Our Adjusters obtain information through a variety of resources; in this situation, prior medical records proved to be a critical reason for the success of this case.  After quickly obtaining past and current medical information and reviewing the accident investigation, Synergy was then able to construct a strong legal argument supported by the facts.

The fact of the matter is the workers’ compensation industry continues to change throughout the years.  Previously, standard accidents could be resolved by adhering to proper medical restrictions with a Return to Work program.  Today, it’s not that simple.  With an aging workforce, unhealthy habits, and healthcare conditions such as obesity and diabetes, claim costs continue to increase and the link between the workplace and an injury becomes unclear.  Increasing numbers of workers’ compensation claims are financially motivated and perhaps even tied to the weak job market, stagnant low wages, access to prescription drugs, and an expanding Social Security Disability program.

Synergy Coverage Solutions is dedicated to providing superior workers’ compensation services and adjusting to today’s reality.  We work hard to stay ahead of the curve and identify programs, such as Fitness for Duty, to ensure employers are finding the right candidates to perform their job duties in a safe and effective manner.  Our dedicated Claims Adjusters aggressively research claims to determine compensability, and are committed to taking a strong stance for the facts a workplace incident may reveal.  In the workers’ compensation industry, Synergy Coverage Solutions stands ready to change with the times to consistently offer superior workers’ compensation services.

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