A Claims Adjuster s Guide to Excess Workers Compensation Insurance Presented by the Safety National Claims Department

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1 A Claims Adjuster s Guide to Excess Workers Compensation Insurance Presented by the Safety National Claims Department This guide provides Claims Adjusters working in TPA and self-administration environments a basic overview of the following topics: 1) The Self-Insurance Option 2) The Role of Excess Workers Compensation Insurance 3) How Primary Insurance Differs from Excess 4) Key Excess Workers Compensation Insurance Coverage Terms 5) Working with Safety National s Claims Representatives The Self-Insurance Option Self-Insurance is an alternative risk funding option favored by employers who seek greater control over their workers compensation insurance program with the least amount of frictional costs. The self-insured employer accepts direct responsibility for payment of its claims while controlling the delivery of workers compensation benefits to its employees through a Third Party Administrator (TPA) or self-administration. By selecting the claims administration option best suited for them, self-insured employers avoid dependence on a primary insurance carrier s claims process that, in many cases, does not have the focused attention necessary to ensure the best outcomes for injured workers. Self-insured employers fall into one of two categories: stand-alone or associations. A stand-alone self-insured is a single employer that is duly qualified by state regulators to self-insure. Associations typically consist of smaller employers that might not otherwise be large enough to qualify on their own who join together to form a self-insurance association or group. A large deductible policy is a form of primary insurance that combines the loss sensitive nature of self-insurance with the structure and some of the expenses of first-dollar coverage.

2 Self-insurance and large deductible workers compensation has grown steadily over the years. When rates for primary insurance became extremely high in the 1970s, companies turned to self-insurance as a more economically viable way to cover workers compensation. Now, almost 50% of America s workforce is covered under self-insured or large deductible workers compensation. The Role of Excess Workers Compensation Insurance Self-insured employers purchase excess coverage to cap their liability on large losses and protect against high claim frequency. Under an excess workers compensation insurance program, the employer retains a pre-determined amount of liability (Self-Insured Retention or SIR) and purchases excess coverage to provide safeguards against catastrophic occurrences (Specific Excess) and unusually heavy frequency of claims (Aggregate Excess). The excess carrier reimburses the employer for covered loss paid above these thresholds, though the direct liability for benefit payments remains with the employer throughout the life of the claim. The employer also remains responsible for claims administration even after its retained liability is exhausted. State regulators are responsible for protecting stakeholders against employers who default on their claim payment obligation. Consequently, regulators may require employers to purchase excess coverage and set maximum policy retention levels. In addition, employers are required to post collateral, often in the form of bonds or letters of credit, as security to cover retained losses. Founded in 1942, Safety National is the longest and leading provider of Excess Workers Compensation coverage in the insurance industry. Most large workers compensation claims take several years to reach the Self-Insured Retention and may take decades thereafter to conclude. In fact, we have open claims in our office dating back to the early 1970s. Our longevity is a testament to the financial security we provide our policyholders. How Primary Insurance Differs from Excess Primary insurance programs include traditional first-dollar policies (also known as guaranteed cost) and large deductible policies. First-dollar policies provide coverage for all losses under a policy period for a predetermined premium amount. The insurance carrier administers all the claims based on their standards and guidelines. The carrier assumes the employer s statutory obligations and becomes a party to claim litigation. Under a large deductible policy, the insurance carrier retains primary liability for benefit payments even though the employer retains most claims within its deductible. As with self-insurance, the employer has a greater degree of control than under a first-dollar policy and may choose to unbundle claims services. 2

3 Key Excess Workers Compensation Insurance Coverage Terms What follows is a description of key policy provisions from Safety National s standard Specific Excess Insurance Agreement (SPWC-0908-A1) most likely to affect the day-today responsibilities of TPA and Self-Administration Claims Adjusters. Service and Administration Requires a separate agreement between employer and a service company approved by Safety National Loss runs must be submitted quarterly Cancellation of the service agreement between the TPA and employer invokes the notice of cancellation provisions in the Insurance Agreement TPA changes must be approved by Safety National Self-administration is also an option if approved by Safety National Claim Reporting The following is an excerpt of the claim reporting requirements from the Prompt Reporting of Claims section of the Insurance Agreement. Section I Prompt Reporting of Claims As soon as the EMPLOYER becomes aware, the EMPLOYER must provide prompt notice to the CORPORATION of: (a) any claim or action commenced against the EMPLOYER which exceeds, or is likely to exceed, fifty percent (50%) of the Self-Insured Retention Per the Declarations and (b) the reopening of any claim in which a further award might involve liability of the CORPORATION under this Agreement. In addition, the following categories of claims shall be reported to the CORPORATION immediately, regardless of any question of potential involvement of the CORPORATION: 1. Fatalities; 2. Paraplegics and quadriplegics; 3. Serious burns, defined as 2nd or 3rd degree burns involving 25% or more of the body; 4. Brain injury; 5. Spinal cord injury; 6. Amputation of a major extremity; and 7. Any Occurrence which results in a serious injury to two or more Employees. If the CORPORATION is prejudiced by the EMPLOYER s failure to provide prompt notice of a claim in accordance with the requirements set forth above and/or as otherwise provided by the Law of any State(s), the CORPORATION may elect to deny coverage for Loss arising from such claim. To constitute prompt, sufficient notice, the EMPLOYER must provide complete information as to the details of the injury, disease, or death. 3

4 Defense of Claims The employer is responsible for the investigation, defense and settlement of all claims The employer shall forward promptly to Safety National copies of pleadings or other claim reports as may be requested Safety National is not obligated to assume charge of the investigation, defense, appeal or settlement of any claim or suit, but shall be given the opportunity to investigate, defend or participate in the investigation and defense of any claims if, in its opinion, its liability might be involved Good Faith Claims Administration The employer shall not unreasonably refuse to settle any claim, which in the exercise of sound judgment with respect to the entire claim should be settled Any settlement involving Safety National funds above the SIR must be approved in advance by Safety National If Safety National is prejudiced by the employer s failure to exercise diligence, prudence, and good faith, it may elect to disclaim coverage Reimbursement The employer pays amounts in excess of the SIR or attachment point and then seeks reimbursement from Safety National A formal proof of loss and supporting documents must be submitted with the reimbursement request Safety National has the right to offset balances due from the employer against reimbursement due Recoveries from Others The employer must prosecute all valid claims against any other party or source Recoveries are first used to pay the expenses of collections and second to reimburse amounts in excess of expenses which go toward reimbursement of payments made by Safety National. Third, any remaining funds are paid to the employer. Other Provisions Separate maximum limit of indemnity per occurrence for Employers Liability claims is a sub-limit of the overall limit One SIR is applied when a workers compensation and Employers Liability claim arise from the same occurrence The SIR is applied once to any one occurrence even if multiple employees are involved 4

5 Working with Safety National s Claims Representatives How to report a claim The first report should contain the information on the First Report form. It should also include pertinent file documents which will allow Safety National to evaluate the potential exposure on the claim. First reports can be sent to Safety National via , fax, or mail. Mailing Address: Safety National 1832 Schuetz Road St. Louis, MO Fax: Contact information Visit our contact page to view claims representatives by state. What happens after a claim is reported to Safety National? After a claim is reported to Safety National, it is assigned to a Claim Analyst specializing in the applicable jurisdiction to the file. Safety National analysts average 17 years of industry experience and see the most costly workers compensation claims from across the country on a daily basis. Analysts work closely with the TPA or self-administered employer to control claim costs while delivering benefits in accordance with the law. After the First Report form is reviewed, an acknowledgement or closing letter is issued. Open files are monitored on a diary cycle appropriate for the severity of the claim. Thereafter, periodic status updates by the TPA adjuster are required so Claim Analysts can participate in the defense of the claim and assess the exposure to the excess layer. Catastrophic claims require a greater level of involvement by Safety National. Safety offers special expertise in medical and claims management to ensure the best possible outcome for the injured employee and appropriate cost control for the employer. Safety National utilizes Best Doctors to help manage medical care for catastrophic and complex cases. In some cases, Safety National will subsidize the cost of Best Doctors if the claim is reported promptly. For more information, please review the Best Doctors section of Safety National s website. 5

6 Safety National s goal is not to compete or conflict with the TPA or self-administered employer, but to support and complement its cost control programs where possible. Through cooperation and communication, the best result for all parties will be achieved. How to request reimbursement Reimbursement requests are treated with high priority and are usually processed the week they are received. Requests for reimbursement should be sent to the Safety National claims personnel responsible for the file (e.g. Claims Analyst). The reimbursement request should include one of the forms below completed and signed, along with a detailed payment listing and a summary of all payments made on the claim by payment category (e.g. indemnity, medical, expense, etc.). Reimbursement request specific excess Reimbursement request aggregate excess Reimbursement request specific excess (pro rate expenses) Case Closure We often close our claim file before final resolution because our evaluation determines that exposure to the excess layer is remote. In such cases, we send a letter advising of the closing and to request re-notification should there be adverse development. Created December 14,

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