Who Has Your Back?

When claims are effectively managed by the insurance company, employers can experience significant savings through a reduction of their Experience Modification Rate.  Below is an example of a case managed by Synergy Coverage Solutions which resulted in an estimated $100,000 savings in additional workers’ compensation costs.  How did just one claim make such an impact on the employer’s bottom line?

An employee had injured her back at work and filed a claim, which was deemed compensable.  It was initially determined, by the claimant’s general physician, that surgery would be required; the claimant received a 2nd opinion also recommending back surgery.  However, Synergy’s Claims Adjuster received two additional opinions, both stating surgery was not required.  The claimant later decided to undergo back surgery.  The claimant requested compensation for lost wages, medical treatment, and surgery costs with estimated total costs of over $200,000.  Who was responsible for coverage?

In this situation, Synergy denied coverage because surgery was not authorized.  The North Carolina Industrial Commission ruled in favor of the employer and Synergy.  The conclusions of law set forth by the North Carolina Deputy Commissioners were as follows:

  • Synergy Coverage Solutions and the Employer have the right to direct medical care
  • Synergy Coverage Solutions and the Employer are not responsible for unauthorized medical treatment.  The surgery was not authorized because it occurred one year later and two medical providers had advised against surgery.

Aggressive claims management and focus on cost containment improved the employer’s Experience Modification Rate.  The decrease of loss reserve directly reduced their Experience Modification to such an extent that the employer will experience a workers’ compensation premium calculation reduction of at least $100,000 over the next three years.  Synergy Coverage Solutions is focused on providing strong claims management as it allows our employers to experience significant workers’ compensation savings over the long term.

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