The Intelligent Insurance Solution

Claims Administration

Reporting Claims

The Trust handles all claims in a prudent manner in accordance with the State of Connecticut Workers’ Compensation Act.  Claims can be reported 24 hours per day, 7 days per week via a toll-free number or online. Claims can also be faxed or emailed. Completed First Reports will be forwarded to the Workers’ Compensation Commission to fulfill the employer’s responsibility.

 Once a claim has been entered into our system, letters are automatically generated to the injured worker and the employer.  The letters outline the claim number, contact information, and other instructional information.

 All claims are reviewed to confirm medical status. An initial three-point contact is made to the employer, injured worker, and physician within 24 hours of every lost time claim.  If necessary, claims will be referred to the nurse case manager for appropriate management.  For serious or catastrophic cases, a nurse is available 24 hours per day, seven days a week.

Bill Payment

The Trust receives and reviews all medical reports to determine compliance with Managed Care guidelines, treatment protocols, and relevancy to the claim.  All medical bills will be reviewed for re-pricing opportunities.  This includes a review by our professional coder to ensure bills are appropriately charged and that the charge is within the fee schedule or a proprietary arrangement established by the Trust.

Ongoing Claims Management

All compensation and permanent partial disability rates is calculated and documented by Trust staff.  Ongoing disability is verified prior to the payment of benefits.  The Claims Manager, Lost Time Claims Representative and the Nurse Case Manager reviews all lost time open claims on a weekly basis in order to determine what can be done to move the case to closure.

Investigation / Determination of Compensability

Trust staff investigates all injuries to determine compensability and causation.  The investigation will be conducted by Trust staff, and will be documented in the claims file and database.  Signed statements will be taken as necessary from witnesses or injured workers with questionable circumstances. All lost time claims are reported to the Central Index Bureau upon creation of a file and frequently throughout the course of the claim.  Each claim is reviewed to determine compensability based on the Connecticut Workers’ Compensation Statutes.

Forms

All required State of Connecticut forms and notices are completed by the Trust. This includes the Employer’s First Report of Injury Form, which is sent to the Workers’ Compensation Commission on behalf of the employer. The Trust will comply with all local, state and federal laws, relative to the administration of your organization’s workers’ compensation program.  All formal claim notices are responded to in accordance with the State of Connecticut Workers’ Compensation Act.  Disclaimers will be issued in a timely manner.

Supervisory Review

The Trust has regular supervisory review of staff performance.  A diary system is maintained by both adjusters and managers to assure limited disability duration.  The Trust complies with all local, state, and federal laws pertaining to cases involving infectious diseases or exposures.  The Trust is available to meet with your organization on a regular basis to discuss claims and program issues.  The Trust monitors the treatment programs of all injured workers to assure quality medical care. As a standard of practice, settlement proposals are discussed with your organization.  The Trust reviews all potential settlements with your organization prior to entering into negotiations.

Reserving

Accurate case reserves are maintained for indemnity, medical, legal and other expenses. Detailed information appears on loss runs and is documented in the system. The Trust reserve practices are in accordance with standard industry practices.

Hearings

The Trust has a Hearing Officer who attends all informal hearings.  This allows for consistent representation with the Workers’ Compensation Commission statewide.  The Trust will work cooperatively with your organization’s legal counsel in all matters assigned.

Litigation Management

Your organization has full choice of legal counsel.  For our own claims, we utilize the firm of Letizia, Ambrose & Falls, New Haven, although we are capable of working with any counsel assigned.

 All claims that require legal counsel will be discussed with your organization in advance.  The Trust will monitor the progress in the case and ensure that it moves forward as expected.  Any concerns will be brought to the attention of the town.

Subrogation Management

Potential claims are investigated thoroughly to determine if there is subrogation potential from a Third Party, Apportionment or Second Injury Fund.  All claims are discussed with your organization prior to any action being taken directly.  The Trust will educate staff members as to the importance of quick notification when a suit has been filed so that we can intervene as quickly as possible.

 The Trust has been very successful in our subrogation efforts.

Fraud Program

The Trust has developed a vigorous program to protect our clients against fraud.  We welcome information from employers that may lead to an investigation, and will keep all information confidential.

 Elements of our program are: (1) a confidential fraud hotline for receipt of information from anonymous callers; (2) fraud posters to display in the workplace; (3) the Trust is a participating member of the Index Bureau, a national clearing house for insurance claim information that assists in fraud detection;  (4) fraud language is noted on the back of each check.

 When appropriate, surveillance is used to gather additional information.  All of our investigators are bonded, insured, and understand the legal limitations and ramifications of their actions.  You will have choice over the surveillance vendor used.

 Over the years, several cases have been referred by the Trust to the State Fraud Unit.  Some have been successfully prosecuted, and financial restitution is being made. 

Return to Work Program

The Trust encourages early return to work on all cases.  Upon clearance or in anticipation of clearance, the Trust will notify your organization’s coordinator to assist in identifying potential restricted duty assignments in order to prepare the injured workers for clearance.

Heart & Hypertension Claims

The trust has been handling heart and hypertension claims for many years for our municipality clients.  We have the experience and most of all stay current with the most up to date legislation, trends, medical procedures, diagnosis, and treatment programs.

Excess Carrier Claims

The Trust notifies the excess carrier of all claims that require reporting.  Pursuit of recovery by the excess carrier will be conducted by the Trust.

Closed Claims

Claims will be closed within 30 days of the last payment or receipt of full recovery.  The Trust will retain closed files for one full year.  Files that have been closed for over a year will be returned to your organization for their permanent storage or the Trust can coordinate off-site storage at the expense of your organization. 

Management Information System

The Trust will enter all data received in a format that will allow for ease of use in the future.  Access to our data base is available at all times during our contract period via online access. The information continues to be updated regardless of the age of the claim.

Online Access

The Trust system documents all actions taken on a file. Your organization will have full access to our online system via the internet, which will allow a review of all demographic data, pay history, reserve history and file notes. All information is password protected, data secure and easy to access.

Annual Reports

The Trust provides an annual Executive Summary which is an extensive volume of loss information, claims information, recommendations for improvements and accomplishments.  This report often serves as the center of discussion for next years efforts in ensuring costs remain as small as possible.

Reports

The Trust provides standard reports that are available online.  These reports can be sorted and downloaded into Excel for further sorting capabilities by the Client. In addition, cost savings reports are provided on a regular basis.

 Samples of available reports are included for your review.