Inside Retail Services News

RS claims analyst successfully challenges unsupported injury payment

Senior claims analyst Michele Whinery recently won a challenge involving an employee who filed a Workers’ Compensation claim for suffering a lower back strain.

Although x-rays showed a pre-existing degenerative lumbar spine unrelated to the job, the claimant’s doctor certified a permanent partial disability (PPD) rating for the worker that directly affects their employer’s Labor & Industries’ account. The worker initially collected a PPD payment of $10,536.24 based on her doctor’s opinion.

Unconvinced that the lower back strain was due to their job with the employer, Whinery asked the Office of the Medical Director to review her concerns, which the office honored. Based upon the Retail Services’ protest, the worker’s doctor agreed to abide by the results of an independent medical exam to settle the protest. The worker failed to appear for independent medical exams.

Whinery pushed for another option of a forensic independent medical exam. Under this option, an independent doctor reviewed the claimant’s medical records and based a final decision on the records. The forensic review upheld Whinery’ s belief that the claim was without merit.

As a result, the $10.536.24 PPD payment was reversed. Labor & Industries also denied the pre-existing degenerative disk disease condition and all of the bills for medical treatment that should now be covered under the worker’s own medical insurance.

This is another example of how Retail Services’ trained claims analysts and adjusters look out for the best interests of the employers who belong to the Retrospective Rating program. Their mission is to guard against unsupported injury claims that unfairly increase expenses for Retro members.

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