Effective claims management has become a sophisticated process and one that draws upon numerous areas of expertise including data analysis, accident investigation, managed care, return to work, subrogation, alternative dispute resolution, structured settlements, and Medicare compliance as well as more traditional areas of claims expertise. Technology is continually evolving allowing the risk manager improved decision-making capabilities. Strong claims management fundamentals can apply to any major line of coverage including general liability, workers’ compensation, and auto liability. This session will explore how to identify key cost drivers, ways to better integrate claims resources, how to achieve faster reporting, the use of performance standards and guarantees, and how to evaluate the quality of your current claims services.

1. Jeff Brody
Divisional Safety Director, Pepsi Cola Bottling Company of New York
Kathy Tazic
Senior Vice President, Client Services, Sedgwick
Vicki Telford
Director, Global Insurance and Risk Management, Hanesbrands Inc.
Tuesday, April 23, 2013
Session Time: 2:15 to 3:30 p.m.

2. Agenda
• Claims investigation
• Medical management
• Disability management
• Litigation management
• Resolution
• Updates and developments
• Q&A

3. Claims investigation

4. Workers’ compensation
• What are the most important aspects of
the claims investigation process?
• Timely witness interviews
• Detailed written report
• Recorded statements where appropriate
• Evidence
• Why investigate a claim?

5. Workers’ compensation
• Questions revolve around these
four basic elements and their
relationship to one another
• Develop a good checklist that
helps identify the pieces of the
accident “puzzle” and how they
fit together
• Job safety analyses (JSAs) can
be very helpful by providing the
foundation of the investigation

6. Workers’ compensation
• Once the information is gathered, it’s time to
get it off to your TPA or insurance adjuster
• Ask 5 “W” questions: who, what, where, when
and, most importantly, why
• Team approach usually works best
• Take pictures and get prompt interviews
• Root causes sometimes are elusive,
but without them, it’s Groundhog Day!

7. Workers’ compensation cost of reporting lag
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
< 3 Days 3 to 7 Days 8 to 13 Days 14 - 30 Days > 30 Days
WC Average Cost
WC Average Cost

8. General liability
• Work from a checklist
• Develop/ personalize your form
• Team effort with insured is critical
• Always keep fraud in your process
• Get a statement from claimant, written or recorded very
early on before they lawyer-up

9. General liability
Try to secure
information from
multiple sources
Look at the scene, take
photos, is there a defect,
was there notice? - get
internal report
Anyone working in the
area? - canvas for
witnesses
Did claimant contribute
to the event?
Was it a product that
caused the accident -
who made it?
Cameras are
everywhere these days!

10. Auto liability
• Paperwork – where is the form
• Pedestrians, bicyclists, skateboarders
• On-scene pix are essential
• Fraud – huge issue in auto liability
• By the way, whose fault is it – witnesses
• Drivers and other occupants

11. Auto liability
• Responders
• Police, fire, EMS
• Accident reconstruction
• Property damage experts
• Distracted driving -
telematics (technology to
capture real-time info)
• Comparative negligence
• Arbitration - we need
another set of eyes and ears

13. Medical management

14. Workers’ compensation
• Roles and responsibilities
• Adjuster
• Nurse case manager
• Utilization review
• Pharmacy benefit management
• What is it and why is it critical?
• Examples of medical management tools

15. General liability
• Sometimes we will get a second medical opinion
on necessity of all treatment, issue of tangential
injuries, soft tissue claims and maximum
medical improvement or future care but this is
usually later in the claim
• Check for priors - do an ISO search - never know
what will turn up - there are way too many
‘professionals’ out there!
• Seldom do we get to manage medical treatment

16. Auto liability
• Medical management of your employees will be
pursuant to workers’ compensation
• No fault - an opportunity for medical mills to do
their $$$ thing
• Not much opportunity to manage driver/other
occupants
• HIPPA laws prevent prying eyes
• Use activity checks – know who your claimant is and
what type of lifestyle they are leading

17. Disability management

18. Workers’ compensation

19. General liability
• May require second medical opinion,
life care plan, modifications to home
or vehicle
• Ongoing physical therapy, prosthesis,
home care may be warranted
• Settlement may need Medicare
approval
• Disability does not mean the end

20. Auto liability
• For your employees refer
to workers’ compensation
• For other driver and
occupants
• Carefully scrutinize injury,
treatment and recovery in light
of severity of collision
• Pay special attention to psych
claims
• Often unable to control third
party Where else? Queens, NY!

21. Litigation management

22. Workers’ compensation

23. General liability
• Work with counsel, share all information available, statements, photos,
claim, previous history of claims from claimant, problems with the site
• Defend or negotiate a settlement - take a position
• Attend settlement/mediation hearings, have pre-arranged range of
agreed upon values
• Let the attorney do the talking - but make sure you understand what he is
saying and why
• Stay away from jury trials in unfriendly venues bent on giving away your
client’s money
• Be ready for day of haggling - it’s an art - learn it!
• 90% of claims can resolve prior to court

24. Auto liability
Ability of adjuster to
resolve matter prior
to litigation
• Settle non-disputed
portions of the claim
Settle v. litigate -
what is your
preference
Work with a team of
trained legal
professionals familiar
with your business
• Clear understanding of
your legal strategies

25. Resolution

26. Workers’ compensation
Some settlement strategies
and considerations:
• Adjuster negotiations
• Mediations
• Use of annuities
When is it a good idea to
settle a claim?
What constitutes an
acceptable result?
Other tools, including
surveillance

27. General & auto liability
• Goal should be to resolve prior to attorney on board - negotiate fair settlement
with pro se claimant
• If the claim is multi-part, settle what you can where liability is clear
• You can still negotiate with attorney prior to S&C – don’t be intimidated - use
mediation or arbitration if far apart
• Review defenses and immunities early on, if counsel agrees, seek a motion for
summary judgment (MSJ)…if not:
• Fact find from involved parties, witnesses and experts
• If unfavorable – negotiate settlement
• Don’t be intimidated by a huge med file
• Use settlement or mediation when possible - if you can’t settle within range of
comfort, get ready to defend

28. Updates and developments