Category Archives: Policyholders

Posting Vacation Photos Online Can Make or Break a Case

Synergy Coverage Solutions’ recent settlement of a claim involving a back injury was reduced by $70,000 due to information gained during our aggressive claims investigation.  Upon injuring her lower back while picking up a patient, the claimant underwent back surgery and was determined to have permanent work restrictions.  Her employer was able to accommodate her work restrictions; however she chose to resign from her position due to unrelated medical complications.

Initially, her attorney demanded a settlement of $90,000, taking the stance that the claimant was permanently and totally disabled.  However, upon deeper investigation of the claim, our Adjuster discovered the claimant had just returned from a trip involving high physical activity, rendering the permanent and total disability claim false.  Synergy was able to provide evidence that the claimant was not actually disabled, which lead to a $70,000 reduction in settlement.

Synergy Coverage Solutions prides itself on diligent and aggressive claims investigation.  Our Claims Adjusters take control of the situation, researching and obtaining details through a variety of resources; in this situation, finding evidence that the claimant was able to participate in high levels of physical activity while on vacation helped us construct a strong legal argument in the case.

A Synergy Moment: How Much Is a Glove Really Worth?

Synergy Coverage Solutions has been in the workers’ compensation industry for nearly 10 years.  In a special series called “Synergy Moments,” we would like to share the situations that capture the true collaborative nature of our business.

In our most recent Synergy Moment, one of our Claims Adjusters noticed a reoccurring injury claim.  Our Adjuster had received several claims from the employer in which employees cut their hands on glass or blades while handling trash.  As our Adjuster was able to note and recall the frequency of these particular injuries from this employer, he notified our Loss Prevention team and brainstormed ways in which this frequent injury could be avoided.  By utilizing special gloves while handling trash, cuts and scrapes would be prevented.  Isn’t the cost of protective gloves worth the spend to reduce employee injuries, as well as claims costs, in the long run?

A Claimant Files a Back Injury Claim – Is It Compensable?

In a recent Claims Success Story, Synergy used medical canvassing to uncover a claimant’s past medical history and ultimately settle the case in our favor.  An employee filed a workers’ compensation claim, alleging he injured his back when lifting an apparatus at work the previous week.  While investigating the claim, our Adjuster used medical canvassing to retrieve prior medical records showing the claimant was receiving medical treatment for his back weeks before the alleged work incident.  Additionally, a written witness statement revealed the claimant complained about back pain when he was new on the job, stating the pain was not work-related, but stemmed from a car accident a few years ago in which back surgery was required.  The medical canvas, combined with the witness statement, helped Synergy prove that the compensability of the claim was questionable.

In this situation, Fitness for Duty assessments would have been extremely beneficial for both the employer and the employee.  These assessments are used to determine an employee’s risk of injury while carrying out typical job duties.  Had these fit-for-duty assessments been completed, the results may have revealed that this individual would have an increased risk of injury due to his previous back surgery, and would not be a safe candidate for hiring in this particular position.

Synergy Coverage Solutions is dedicated to helping employers control workers’ compensation costs and investigating every claim thoroughly for compensability.  To learn more about hiring practices and Fitness for Duty testing, click here or contact us by email here.

Why Should Background Checks Be Included in Your Company’s Hiring Practices?

Including background checks in your company’s hiring practices is a smart business decision, as it is one step you can take to minimize the risk of a bad hiring decision.  How will employers be able to tell if a future employee will be a valuable asset, or a big liability?  Hiring an individual who is not appropriate for the job can lead to increased business costs, lost productivity, and damage to your company’s reputation, among other issues.

What are the major benefits of performing background checks on prospective employees?

  • Protection of your company and employees from potential theft, workplace violence, closure, and other legal issues
  • Preservation of your company’s image and reputation – staff is a direct reflection of your company
  • Controlled workers’ compensation costs: 13% of workers’ compensation claims are fraudulent (exaggerated, fake, or old injuries), leading to higher workers’ compensation premiums and less productivity
  • Clear separation of trustworthy job applicants from those that are dishonest on their resume, as 50% of resumes contain false information
  • Completing a background check is less expensive than dealing with disruptions in the workplace, liability and legal issues, financial loss, decreased productivity, turnover, etc.  Even a simple internet search can convey valuable information about prospective employees (and public records that may include driving records, criminal records including wants and warrants, sex offender records, court records, and various licenses including professional and business licenses).

Including background checks can help prevent bad hires and avoid problems that may be caused by hiring an individual that is not suitable for the job.  Hiring the wrong person can cost employers tens of thousands of dollars…isn’t a background check a valuable investment to ensure your organization is hiring an individual that is the right fit for the job?

Top Reasons Medical-Only Claims Turn Into Lost Time Claims

Medical-Only Claims typically involve minor injuries containing no lost time, no impairment ratings, and no associated compensability questions.  These types of claims usually require little or no investigation.  However, there are times medical-only claims turn into lost time claims – increasing workers’ compensation costs and decreasing productivity for the employer.  Below are the top reasons medical-only claims can turn into prolonged lost time claims:

  1. Improper medical care.  Injured employees may seek medical treatment from their family physician.  Although they may feel more comfortable with their routine physician, the physician may be unaware of or unfamiliar with the employer’s policies regarding transitional/light duty programs.
    *States in which employers are permitted to direct medical care (NC, VA & GA) should have a medical providers list clearly posted so employees are aware of their designated medical providers in the event a workplace incident occurs.
  2. Employee’s perception of injury.  When an employee sustains an injury at work, he or she may think it’s “nothing serious” and continue to work, while not informing anyone of their incident, and perhaps further aggravating the injury.  It is important to ensure all employees are aware of your organization’s accident reporting policies and report all incidents, no matter how small.
  3. No telephonic physician service.  A telephonic physician service allows the employer and injured employee to speak with an experienced physician to assess the injury and direct medical care.  The employee can receive immediate instructions, whether it is self-care or a visit to the designated medical provider, and receive appropriate care in a timely manner.
  4. Inattention to detail and missed communication.  Workers’ compensation fraud is extremely prevalent – it is important for an employer and their Claims Adjuster to determine the nature and extent of an injury immediately, before an employee can take advantage of the situation.
  5. Taking advantage of a valid injury.  Injured employees may be inclined to take advantage of a valid injury and receive time off work while recovering from their injury – while not aware of the employer’s Early Return to Work and Light Duty policies.  Employers should clearly advise employees of obligations to their Early Return to Work and Light Duty programs when possible.
  6. Employer does not offer Early Return to Work & Light Duty programs.  Early Return to Work and Light Duty programs are instrumental in helping injured employees return to maximum capacity in the least amount of time and help control workers’ compensation costs for employers.
  7. Insurance costs.  With insurance rates constantly rising, increasing popularity in high deductible plans, and out-of-pocket medical expenses, injured employees may be tempted to take advantage of workers’ compensation in order to dissipate costs incurred personally.
  8. Employees’ sense of worth.  Employees that are not feeling valued by their employer may believe the employer “doesn’t care about me” and carry on that mentality throughout recovery.
  9. Employee resistance to Early Return to Work programs.  Injured employees may try to convince their physician they are in too much pain to return to work, even under light duty, as they may be preoccupied with taking time away from work for vacation, child care, spousal care, elder care, etc.
  10. Prescription Drugs.  The use of narcotics in workers’ compensation continues to be a problem, driving up medical expense for the employer while potentially inhibiting the injured employee from reaching full recovery and a higher likelihood of abuse, addiction, or overdose.

How is Synergy Coverage Solutions actively working to prevent these types of occurrences from happening?

  • Aggressive claims investigation.  Our Claims Adjusters perform due diligence in claims investigation and in-depth research on claims that may be fraudulent.  They are trained to think critically and creatively to bring the claim to an equitable close while performing a full investigation of the claim to piece together all details of the claim.
  • Constant communication with the injured employee, employer, and medical provider.  Claims Adjusters are in constant contact with all parties involved throughout the life of the claim in order to stay up-to-date on the injured employee’s condition and progress.
  • Experienced Loss Prevention Consultants.  Our LP Consultants can assist employers with implementing transitional duty/ERTW programs that fit your organization’s unique needs and goals, complete with transitional duty task lists.  Our LP Consultants can also help employers implement Accident Investigation procedures to help both the employer & Synergy Coverage Solutions determine the nature and extent of workplace incidents, while attempting to prevent similar, perhaps more disastrous incidents from occurring in the future.
  • Enhanced medical network.  Our extensive network of credentialed and qualified physicians offer effective medical care at a significant cost savings, and are also familiar with Early Return to Work and Transitional Duty programs.
  • Telephonic Physician hotline.  Our physician hotline allows organizations to speak to physicians over the phone to assess the injury and direct treatment, whether it’s self-care or a visit to a nearby medical provider.

Synergy…Working Together to Prevent Injuries

Synergy often utilizes communication between our Claims and Loss Prevention departments to enhance our customer service and experience.  Recently, a Claims Adjuster recognized a dangerous machine guarding situation while reviewing a minor claim generated by a near-miss (stemming from improper machine guarding).  Immediately, the Claims Adjuster communicated the cause to one of our Loss Prevention Consultants.  With this information, Loss Prevention was able to schedule a safety meeting with the organization and assist with corrective action to prevent future, perhaps more serious, injuries.

While this may sound like a simple occurrence, this is just one example of how Synergy goes above and beyond to protect our policyholders.  Because we are big believers in effective communication and collaboration, the way we do business only offers an even more enhanced effect for our customers.

To learn more about our Loss Prevention services, please visit or contact us at

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.

Fatal Work Injuries Decreased in 2012, Compared to 2011

The Bureau of Labor Statistics’ National Census of Fatal Occupational Injuries has released preliminary results to show a reduced number of fatal work injuries in 2012, compared to 2011.  In 2011, 4,693 fatal work injuries occurred, whereas in 2012, the number of fatal work injuries decreased to 4,383.  Secretary of Labor Thomas E. Perez states, “Workers in this country have the right to return home safe and healthy at the end of a work day.  Despite that right, poor safety conditions cause thousands of people each year to lose their lives at work.”

Synergy Coverage Solutions is dedicated to helping employers create safer workplaces for their employees.  The best antidote for preventing workplace incidents is to implement effective loss prevention programs that are tailored to each company’s needs.  To learn more about a few of our Safety Programs, click here:

Click on the following link to read the statement made by Secretary of Labor Thomas E. Perez:

How Does Employee Health Affect Workers’ Compensation?

In 2004, the number one health risk in the United States was obesity, according to the U.S. Centers for Disease Control and Prevention (CDC).  Any individual with a Body Mass Index, or BMI, of 30 or greater is classified as obese.  BMI is calculated by taking an individual’s body mass, in pounds, and dividing that by the square of their height, in inches.  That number, multiplied by 703, is their BMI.  Individuals with a BMI less than 18.5 are classified as underweight, 18.6-24.9 are classified as the recommended weight range, 25-29.9 are classified as overweight, and 30+ are classified as obese.

The obesity rate in the United States has changed drastically in the past twenty years.  In 1990, the majority of the United States reported only 10-14% of its state population as obese.  In 2000, the majority of the United States reported 15-19% of its state population as obese.  In 2010, the majority of the United States reported 25-29% of its state population as obese.  Today, approximately 1/3 of the U.S. population is obese.  The prevalence of obesity has significantly increased in today’s world, which can directly impact your business, your business’ productivity, and your employees’ health and safety.

How does obesity affect workers compensation?  According to a 2007 Duke study, as BMI increased, the incident rate of workplace injuries increased, as well as workers compensation costs.  Additionally, obese claimants had a longer recovery time and wider range of medical treatments and costs, compared to employees at the recommended weight with similar injuries.  Also, as injured workers are not working, there is a greater risk for additional weight gain, making it even more difficult to return to work.

To learn more about the effects of employee health on workers’ compensation, click on the following link: and Workers Compensation.pdf

What Businesses Should Know About MSAs and How it Affects Workers’ Compensation Claim Costs

What is an MSA?  Medicare Set Aside, or MSA, is a portion of a settlement between a claimant and the workers compensation insurance company that allocates funds to be used on future medical expenses that would otherwise be payable by Medicare.  The funds in an MSA account should only be used on a claimant’s future medical expenses that are a direct result of work-related injuries, illnesses, or diseases sustained while on the job.  If the MSA funds are exhausted and additional medical expenses are incurred, Medicare will then start coverage for the claimant.  If a claimant passes prior to exhausting the MSA, the funds will then go to the designated beneficiaries under the MSA agreement.

Who is eligible for an MSA?  Anyone that is 65 years or older is eligible, as well as anyone with a reasonable expectation to be enrolled in Medicare within 30 months of a settlement exceeding $250,000.  Additionally, claimants who have filed for Social Security Disability, or may file for Social Security Disability within the next 3 years, are eligible.  Just to give some insight, the number of disabled workers receiving Social Security Disability has significantly increased in the past seven years.  In 2006, 6.8 million disabled workers received Social Security Disability.  By 2013, the number has reached 8.9 million – not only increasing the disability roles, but also increasing the workers compensation claimants eligible for a Medicare Set Aside. In 2007, Section 111 of the Medicare, Medicaid, and SCHIP Extension Act created the MSA for workers compensation (and other lines of insurance) and became effective on July 1, 2009.

How is the MSA allocation amount determined?  The MSA allocation amount is determined on a case-by-case basis, calculated using an anticipated amount of future medical care, including pharmacy expenses, (based on current medical records) and the remaining life expectancy of the claimant.  The Centers for Medicare and Medicaid Services, or CMS, will review proposed allocation amounts for settlements over $25,000; however, CMS approval of a proposed MSA allocation amount is not required.

How do MSAs affect workers compensation costs?  MSAs directly affect a business’ experience modification and loss results, therefore having the potential to increase workers compensation premium for the business.  In addition to claims being more expensive, MSAs can also make claims more difficult to settle and close out future liability.

Synergy Coverage Solutions is dedicated to helping employers proactively provide safe work environments for their employees, while also controlling workers compensation costs.  Preventing workplace injuries is just one way businesses can have more control over workers compensation costs.  If you have any questions about MSAs, feel free to reach out to our workers’ compensation specialists at