How to Show Care for Injured Employees and Avoid Litigation

Tips from PartnerSource

When a client receives a letter of representation, it’s always interesting to review the claim file to identify what likely caused the employee to retain an attorney. In many reviews, we see that the employee’s benefit claim was denied, often without the claims administrator first speaking with the employee.

Our many years of experience helps PartnerSource understand that it’s often not the benefit denial itself but how the denial was handled that is the reason behind a claimant retaining counsel. In fact, this happens more often than not.

So, how can a benefit denial be handled in the best way possible?

Have a conversation. First, if a benefit claim cannot be covered, it’s important that the employee receives a phone call from the claims administrator explaining why the claim cannot be covered and how the employee can file an appeal if they disagree with the decision. A big benefit of this conversation is it gives the employee an opportunity to ask any questions they may have. Without that opportunity, they may turn elsewhere for answers.  

Be specific in your letter. Following the conversation with the employee, ensure the benefit denial letter the claimant receives thoroughly explains the reasons why the benefit claim cannot be covered. For example, if the employee’s injury did not arise out of the course and scope of employment, explain why. Was the employee injured on a work break or commuting from their home to their normal work location? Taking the time to include those details also helps the employee better understand why the claim cannot be covered.

Provide continuity. If the employee has company-provided benefits, PartnerSource suggests the client and the claims administrator provide the employee with a “soft hand-off” to a professional in the company’s Human Resources or benefits department. That person should then have a conversation with the employee to discuss company-provided benefits like health insurance or short-term disability and then help the employee navigate access to those benefits.

Call PartnerSource. Finally, if a benefit claim cannot be covered under the plan and the employee is upset and/or threating to retain an attorney, reach out to your PartnerSource team to talk through the facts of the claim and determine if it would be beneficial, for paternalistic or liability reasons, to offer the employee an out-of-plan settlement in return for a release of liability. Sometimes, doing something as simple as offering to help the employee cover a portion of their health insurance deductible can make the employee feel cared for and avoid litigation.

In a perfect world, no one gets hurt, on the job or off. However, people do experience injury and businesses should continue to turn to PartnerSource for the counsel and insight that has earned PartnerSource its reputation as the leading provider of expertise for those in the Texas Option industry.