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Ochoa & Calderon

Who’s the Adjuster in a Workers’ Comp Case?

Patient health insurance claim form in doctor or nurse hands for

After an injury at work, you have the right to seek workers’ compensation coverage. Your employer and their workers’ comp insurance provider should step in to help you get the medical care you need and repay you for lost wages resulting from days missed at work. When you file for workers’ compensation, you are assigned a workers’ comp claims adjuster to process your claim. Continue reading to learn about the role of a workers’ comp claims adjuster. If you’ve been hurt on the job in Southern California, call a seasoned Riverside workers’ comp benefits attorney for help collecting the benefits you are owed.

What Does the Workers’ Comp Claims Adjuster Do?

Your workers’ comp claims adjuster is meant to facilitate and coordinate your workers’ comp claim. They’ll help set up your appointments with the treating physician and generally monitor your recovery, including through periodic check-ins. These check-ins may come in the form of an informal call or email, or a formal letter requesting certain documentation. Claims adjusters have a number of duties during the pendency of your claim, including:

  • Investigating your workers’ comp claim to determine the cause of the injury, the validity of the claim, and the severity of your injuries
  • Gathering information from your employer about what occurred and how it happened
  • Talking to witnesses and others with information about your injury
  • Making a determination as to whether your claim should be covered
  • Coordinating appointments with your doctors
  • Approving or denying medical care, certain treatments, certain surgeries, or certain healthcare providers
  • Making determinations regarding the total value of your case
  • Making settlement offers concerning your benefits

These are just a few of the duties claims adjusters may have, depending upon the insurance company. One of their most important duties will be generally monitoring your recovery and reporting back to the insurance company about your injury, your recovery, and your claims.

Is the Claims Adjuster on Your Side?

When dealing with the claims adjuster, it’s important to keep one thing in mind: The claims adjuster works for the insurance company. Their goal is to get you back to work as soon as possible and otherwise minimize the value of your claim. When they speak with you, you should always consider the conversation to be “on the record,” and you should assume they are hoping for information that will lessen the value of your claim.

The claims adjuster will ask you to make a recorded statement early on, during which they will ask you a series of questions about your accident such as how it happened, what you were doing just before the accident, whether you went to the doctor straight away after the accident, what kind of medical care you are receiving, and your prognosis. Even outside of these “recorded statements,” however, anything you say can get reported back to the insurance provider. Be careful and avoid giving them a reason to doubt the severity of your injury, which could lead to your coverage being limited or your claim denied.

After your workplace injury, the only person truly on your team is your workers’ comp lawyer. Employers and insurance claims adjusters are looking to limit their liability, not to help you get the medical care you need. Your workers’ comp attorney is there to maximize the value of your claim and ensure you get the medical care, the rest, the lost income, and the benefits you deserve.

In fact, you do not even have to talk to the claims adjuster personally; your lawyer can handle those communications for you. Talk to a seasoned workers’ comp attorney to make sure you present the strongest case for maximum compensation.

If you or someone you love has been seriously hurt on the job in California, get help seeking the workers’ compensation benefits you’re owed by contacting the Riverside offices of Ochoa & Calderón for a consultation on your case.

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