On this episode of the WorkSAFE Podcast, we sit down with Shannon Fox, Claims Operations Manager at MEM. Claim length varies from case to case. A claim that lingers for months—or even years—can create uncertainty, increase costs, and impact both the injured worker and the business.
Several factors, such as medical complications or legal roadblocks, can keep a claim open longer than expected. Some business owners see a claim closed in just a few weeks. Other cases take much, much longer, leaving key questions. Why are claims delayed? What can employers do to help keep the process moving?
Listen to this episode of the WorkSAFE Podcast, or read the show notes below.
How long will a claim stay open?
For both injured workers and employers, there is one common question after a workplace incident and injury. How long will a claim stay open? Fox points to several factors that ultimately impact claim length: injury severity, required medical treatment, and disputes. No claim has an exact timeframe.
“A simple claim, like minor injuries requiring minimal medical treatment, may resolve in weeks or months, right?” she points out. “But it’s when you get to the more complex claims that may involve surgery and detailed treatment or disputes, it can extend from several months to several years.”
What makes a claim complex?
There are two common types of claims: medical-only and lost time. Medical-only claims only involve medical treatment. The injured returns to work after receiving it. A lost time claim involves time away from work while an injured worker receives treatment and recovers. The claim length on both is shorter, lasting anywhere from 90 days to a few months. Claims often become more complex for the following reasons:
- A detailed investigation is required. If more details are needed to understand how or why an incident happened, then more time is needed to gather them.
- Attorneys are involved. An injured worker may secure representation for themselves, and then an employer may do the same. Attorneys also become involved in cases of subrogation, where a third party may be at fault for causing an incident.
- The resulting injury from a workplace incident is catastrophic. For example, an amputation, spine injury, or severe burns. Multiple payments may be needed for medical procedures, lost time, and continued care.
In some cases, an adjuster or field representative will travel to the incident scene. Fox explained that the larger the loss, the more important it is to have as much information as possible.
Does litigation add to claim length?
When a claim enters the legal arena, time will inevitably be added to the claim length. “Litigation will usually always extend the life of a claim, right?” Fox shared. “And that is because we have another party involved that is working on behalf of the injured worker.”
Litigation delays a claim in two ways. First, a third party enters the claim, wanting to obtain something on behalf of the injured worker. Second, direct conversations with the injured worker can no longer happen. All inquiries must be routed through the attorney, creating a middleman and slowing down communication.
The role of medical uncertainty
Workers compensation laws determine how and when a claim can be considered a compensable work-related injury. The prevailing factor, or the main reason why an illness or injury happened, is an important element in this process. When the prevailing factor is unknown, or extensive, claims adjusters must bring in specialists to help determine it.
In most catastrophic claims, the prevailing factor is essential to determine and may take time to understand. Fox highlights that these cases involve everything from multiple injuries to paralysis, and can extend to traumatic brain injuries and fatalities. The medical treatment required is significant.
“As we gravitate toward the more severe issues, we need specialists to clarify the details of the injury. Is it truly work-related?” she explained. “And a lot of that just adds life onto the claim based on the severity and the details that are involved in it.”
Severe injuries: Does the claim stay open forever?
In some workplace incidents, the resulting injuries are severe enough that the worker may never fully recover. For instance, falling off of a roof could result in several different types of injuries: head, back, internal bleeding or injuries to organs. Even if the injured worker recovers some function, they may never be able to walk or live independently again.
In these cases, the claim is monitored for maximum medical improvement (MMI). At this stage, an injured worker’s physician determines that they have recovered as much as they can. While they may still have occasional appointments or take medication, they are no longer doing it to improve, but to maintain their current state.
“Everything that we do is based on the information we receive from the treating physician,” Fox said. A portion of the claim may be closed if it’s determined no more physical improvement can be had. If the injured worker needs continued medication, therapy, or even lifetime monitoring of medical devices, the claim will stay open to meet those needs.
Claim length: 3 things employers can do to help efficiency
Employers play an important role in ensuring claims get off to an efficient start. Fox highlights that claims move faster when employers take a proactive and supportive approach. What does that look like? Employers should:
Train employees on claims reporting
Employees skip reporting injuries for various reasons. For example, they may not know when to report, fear retribution for ‘causing trouble’, or worry about inconveniencing their employer. However, delaying or seeking out unauthorized treatment can ultimately worsen an injury.
Train your employees on how and when to report an injury. If you can’t be there, ensure they know how to take action without you. First aid training can empower employees who work in rural areas or travel to job sites. Solutions like a triage program allow them to access professional help, even if an authority figure isn’t on-site.
Investigate workplace incidents
Important details are freshest right after an incident happens. Report an incident within 24 hours and start gathering information as soon as possible. Did someone witness the incident? Was the incident caught on video? Take statements and gather any useful evidence.
Support injured workers
If you don’t provide support for an injured worker, then they’ll find someone else to do it. In many cases, this support takes the form of an attorney. Not only does this slow the claim process, but it also creates building resentment between the injured worker and their employer.
Check in regularly on injured workers. “When employees feel valued, they may be less likely to seek legal assistance, and that could definitely speed up the resolution of the claim.”
Another way to support injured workers and shorten the length of a claim is to set up a return to work program. This allows them to get back to work, either on modified duty or as volunteers, as soon as they’re physically able. Not only does it improve their mental health, but it also helps them stay conditioned for a work environment and demonstrates an employer’s commitment to getting them back on the job.
A responsive employer: The biggest impact on claim length
For Fox, the way an employer responds to a claim makes the biggest difference in its length and outcome. This involves three key responsibilities: clear communication, timely medical care, and a supportive approach to injured workers. “A well-handled claim benefits everyone – the injured worker, the employer – because it reduces the amount of money they pay out,” Fox shared. “And it also makes that employee feel as if their employer cares about their overall health.”