By Carrie Millar, FDA Services Director of Insurance Operations
First, let me begin this article by stating that our FDA Services’ (FDAS) team is constantly striving for outstanding customer service. We are always surveying our member clients on how well we are doing and how we can improve. On top of that, we are looking for insurance and service partners that also strive for superior customer service.
FDAS has been partnered with The Zenith, a workers’ compensation carrier, for over ten years and I have always been impressed with the service their underwriting staff provides our team. Their management consistently reaches out to make sure that we are happy. A few years ago they invited me to visit their offices to sit in on a staffing meeting-I took them up on this.
What is a staffing meeting? This was my first question when I arrived at their headquarters in Sarasota, FL. I had assumed that the meeting would show me how they rallied their troops and company morale. I pictured a room full of underwriters, sales reps, and other employees shouting out sales numbers and celebrating profit. I was wrong! A staffing meeting is how the company reviews unique claims and ALL coverage declinations.
How does it work? A team consisting of a staff physician, staff lawyer, claims VP, special investigation unit rep, and rotating claims adjusters meet twice a week to review regional claims. This occurs at the Sarasota office on Tuesday, Thursday and the Orlando office on Monday and Wednesday. They collaborate on the claims presented that day and determine if, based on standardized industry language of DWC-12 compensability for the State of Florida, they will be paid.
Why is this unique? In my almost twenty years working in the insurance industry, I have never heard of this. Typically, with other carriers, workers compensation insurance claims are assigned to an adjuster and the adjuster makes the decision. If you do not agree with the decision then you complain to their manager and must work your way up the management ladder. Some carriers do have a formal appeals process but they tend to be closed doored and held monthly. This is the first time I have seen a collaborative approach to insurance claims besides medical malpractice claims.
What I experienced? I sat down in the office of the assistant VP of claims, the chief medical examiner, , a senior trial attorney, a fraud investigator, and several claims examiners (adjusters). I was given a scrubbed list (to protect client information) of the claims that were to be discussed. I was also given a sheet of the 21 standard DWC-12 notice of denial statements for the state of Florida.
Claim #1 Employee Amy, employed by an insured restaurant, was touched by a co-worker with latex gloves. She had an allergic reaction to the gloves, was treated at an outpatient facility, and returned to work. Discussion: Did she know of her allergy? Yes. Did the restaurant know? Yes. Could an accident have been avoided? No. Decision: The team decided to cover her initial medical bills from the initial touch but declined any additional claims, as latex allergy is a pre-existing condition.
Claim#2- Employee Erika, employed by an insured restaurant, went to a laser tag event that was paid for by the restaurant. She fell, chipped her tooth, and had to have a crown put on. Discussion: Was she paid to attend? No. Was it strongly encouraged? No. Did it produce benefit to employer other than goodwill and employee morale? No Decision: Declined because the accident was not sustained in the course and scope of employment. This was as two-pronged declination because the event was optional and the employer did not directly benefit from attendance.
Claim #3- Employee Jose is employed at dairy farm. The insured Employer asked that this be staffed, and the initial decision was to pay the claim in full. Jose is 43 and has worked at the dairy farm for 16 years, first as a milker and now parlor manager. He reported hand/finger pain but did not know the cause. He went to the doctor for treatment and was told it was from repetitive motion. He has a total of nine prior claims but he has been there for 16 years. Discussion: What were the other claims? Minor accidents from farm work, all medical only treatment. Did he return to work? Yes. Does the dairy use mechanical machinery to milk cows? Yes, but the cows must be cleaned prior and machinery put on. Technology has advanced in the last 16 years but he worked as a milker for over 8. Decision: Covered fully
Claim#4- Employee Maria has been employed at an insured farm 2 years. She was driving a utility truck and struck a tree. She sustained a stomach area injury and was treated at PCP. A MRI was done of the lumbar and metastatic disease was discovered and it may have spread to bone and spine. A treatment plan for cancer has been started. Discussion: Was this known? No. She had an MRI two years ago and clear. Was she supposed to be driving? Yes. Decision: Initial PCP visit covered. The rest of the claim is declined for the major contributing cause of the need for treatment or disability is no longer the industrial accident. They will offer a settlement on a denial basis.
At end of my experience I went away feeling even stronger and more assured in offering The Zenith to FDAS clients. Policyholders and their employees are not a number and all claims are taken seriously. I thank Zenith for sharing their process with me.
Call FDA Services to learn more about securing workers compensation insurance with The Zenith, 850-681-2996.