I Disagree With My Insurance Company, Now What?

Hello, everyone.

When your insurance company denies a claim or offers less than you believe is fair, the next steps can feel overwhelming.

The claims settlement process can be complex, and insurance companies have a method for evaluating them.

Today, we will discuss practical options available when you find yourself at odds with your insurer.

On behalf of McGriff, I would like to take this opportunity to thank each of you for joining us today as we discuss,”I disagree with my insurance company.

What’s next?”My name is Lesonya Wilder, and I will be your host for the call today.

There are just a couple of housekeeping points that I would like to share with you before we get started.

This is a live session, and you are in listen mode only.

If you have any questions at any time during the presentation, feel free to utilize the chat box or Q&A box to type in your questions, and we will address them during the Q&A segment.

If time doesn’t permit for us to answer the questions after the presentation, we will be sure to capture them and provide the responses afterwards.

Now, it brings me great pleasure to introduce to you our speaker for the hour.

We have John Rabon, a claim consultant with McGriff.

John is a resource and advocate who is focused on reducing his clients’ total cost of risk.

He works to contain costs that drive insurance premiums by overseeing claims management, experience modification reduction, and loss prevention.

An insurance industry veteran since 1989, John provides an active voice for his clients and is a significant resource in resolving challenging claim risk management issues.

While working as a liaison between clients and insurers, he has strong working relationships with claim managers for several insurance companies and has experience with claims involving all types of coverage for clients in several different industries.

John earned his bachelor’s degree in science and business marketing from Elon University.

He holds a North Carolina justice license and the Commercial Lines Coverage Specialist designation.

So without further ado, I will turn it over to John to kick off the presentation.

Thank you, Lesonya.

I appreciate that introduction, and we appreciate everybody joining today.

Our goal is to take some of the mystery out of claims denials and give you the understanding and tools to challenge them when appropriate.

As Lesonya said, I have been in insurance since 1989.

I’ve spent my career working as an adjuster with several different insurance companies prior to coming to McGriff as a claims advocate approximately six years ago.

So I thought this would be a great opportunity to talk about denials and whether or not you have options to push back and challenge them, depending on the circumstances.

I wanted to talk a little bit about terminology clarification before we start.

I may use the words insurance company, insurance carrier, or adjuster.

I’ll use those interchangeably.

I’m always talking about the insurance company when I say that.

I also may use the term policy or policy form.

When I say that, I’m actually referring to the actual policy itself.

Okay, so what we’re going to cover today, we’re going to cover three specific lines of coverage.

We’re going to talk about commercial auto, commercial property, and workers’ compensation.

On each of these, we’re going to talk about how the policy works, what common exclusions you will see, and what you would need to contest a denial.

Now, a lot of times when we see a denial, we’ll look at it, and it’ll come to us, and we’ll immediately think,”Well, I pay insurance.

They should cover that.”And that’s an emotional reaction.

So as we get a little bit deeper in the presentation, what we want to do is we want to look at how we can push back when appropriate on those denials.

I don’t know if any of you are a Marvel fan, but I’m a huge Marvel fan, and I got the opportunity to go see”Spider-Man.”And in”Spider-Man,”one of my favorite characters is the Hulk.

Now, a lot of times when we see denial, we’ll look at it, and it’ll come to us, immediately think,”Well, I pay insurance.

They should cover that.”And that’s an emotional reaction.

So as get little bit deeper in the presentation, what want do is how can push back appropriate on those denials. don’t know if any you are Marvel fan, but I’m huge got opportunity go”Spider-Man.””Spider-Man,”one my favorite characters Hulk.

And the reason why that is important in our conversation today is you need to step back and ask yourself, when you have a denial, are you reacting like Bruce Banner or are you reacting like the Hulk?

If you think about both of them, Bruce Banner is very logical.

He thinks through things clearly.

He makes his points clearly.

Versus the Hulk.

The Hulk is just upset.

You can’t reason with him, and he’s very emotional.

Obviously, when we’re dealing with an insurance situation, particularly a claims denial, there is a lot of emotion there. reason why that important our conversation today need step ask yourself, have reacting like Bruce Banner or Hulk?

If think about both them, very logical.

He thinks through things clearly. makes his points Versus The Hulk just upset.

You can’t with him, he’s emotional.

Obviously, we’re dealing insurance situation, particularly claims there emotion there.

However, we need to step back.

We need to use logic, analysis, and reasonable rebuttals rather than being angry and emotional.

We can actually challenge an insurance company denial if you understand what the denial is based on, and you can offer and tailor your rebuttal to the interpretation of the insurance adjuster while using the policy language.

So, as I said in the beginning, I actually work as an adjuster, and one of the things that I heard when I was handling claims, particularly claims denials, is I would have people ask me,”Do you get a percentage of savings if you deny a claim?

However, back.

We use logic, analysis, reasonable rebuttals rather than being angry actually challenge company denial understand based on, offer tailor your rebuttal interpretation adjuster while using policy language.

So, said beginning, work adjuster, heard was handling claims, denials, would people me,”Do percentage savings deny claim?

Do you get an award if you deny so many claims per month?”And I get it.

They were emotional and upset about it.

But what’s really going on in an adjuster’s mind when they’re handling claims?

So let’s talk about that a little bit from the adjuster perspective.

We’re dealing with, on an individual insured basis, one, two, maybe three claims a year.

Do award so many per month?”it. were upset But what’s really going adjuster’s mind they’re claims? let’s talk from perspective.

We’re with, individual insured basis, one, two, maybe three year.

Hopefully, things are going well.

So we’re able to look at just a small number of claims.

An adjuster may be looking at 75, 100, 150 claims.

So what are they trying to do?

They’re trying to get those claims closed, and that’s really what they’re focused on.

And by focusing on closure, they may not be reading the policy fully.

The other thing that they’re looking at from an adjuster standpoint is regulatory guidelines.

They can’t just deny a claim.

They have to understand exactly how it fits into the policy.

And because of state regulations, you have to make sure that denial is focused on state guidelines as well as following the policy language.

The other thing that is somewhat surprising to people, sometimes the adjuster may not have even read the policy.

They’re handling a high volume of claims.

Policies change.

You have one policy.

You have insureds that may have different policies written at different times.

They may not all be the same.

In order to figure out whether that denial is accurate or not, you have to read that individual policy.

I’ve actually spoken to adjusters before on claims, and we talked about a denial, and I’ve asked where it was in the policy, and I’ve actually had them admit to me,”I haven’t really read the policy, but I had a claim similar to this one time, and I’m pretty sure this is not covered.”Well, that actually doesn’t cut it.

We really need to see what the policy says to understand whether it’s covered or not.

The other thing I would add to that before moving on to the next slide is sometimes there’s an internal debate within the insurance company as to whether something’s covered or not.

We’ve had situations where we put 10 adjusters in a room, we’ve looked at a claim scenario, and we’ve had three or four different interpretations.

And the reason why that is, is because sometimes the policy language is not black or white, it’s very gray.

So depending on how you review it or depending on what focus you put on it, you may see it entirely differently than someone else that read the exact same policy.

So why do insurance companies deny claims?

Well, the first reason they deny claims is the loss just isn’t covered.

The policy has specific exclusions or gaps.

There are certain things like floods or certain damage that’s not covered.

And one of the things I always ask is, have you read your home or auto policy?

Most people have not.

So if you haven’t read it, you really don’t know what’s in it.

We really don’t have a reason to read it unless you’re an adjuster like I am and are just curious until a loss comes up.

But we really need to always refer back to the policy to understand what’s there.

One of the things that I would like to point out is you need to think of the policy like a contract.

And as a contract, it outlines everything that an insurance company must do, the things that are covered, the things that are not, as well as what your obligations are as the policyholder.

So when you step back and you look at it like a contract, you can go to it and you can say,”Hey, is this covered based on these circumstances, or is it not?”Remember, denials are based on the interpretation of the policy language.

That can vary.

What’s another reason that claims are denied?

Well, you didn’t follow the rules.

You have to report the claim timely.

If you don’t report the claim timely, the insurance company may say that they were prejudiced.

And what that means is they weren’t given time to investigate the claim.

They weren’t given time to gather information.

Maybe by not following rules, you didn’t send in forms that the insurance company had asked for, or you didn’t cooperate with their investigation process.

Sometimes the question comes up of if an adjuster insurance company asks for pieces of information that relates to the claim, do I have to provide it?

Well, because you are the person that’s insured, yes, you have to provide it.

They’re not actually trying to be difficult.

They’re not trying to send you on a paper chase.

But from an adjuster standpoint, what they’re looking for is they’re looking for sufficient documentation in order to pay the claim.

And so remember when I talked about regulatory guidelines, they have to make sure that they’re consistent.

So you may be looking at one claim, they may be looking at five that are very similar, but they still have to make sure that they’re following the steps in the process.

So you need to make sure that you understand what the rules are and that you’re following the rules.

And most requests for documentation is going to be fairly straightforward.

The other thing that comes up is maybe they’re still investigating.

It may be a complex claim.

There may be a lot of information that has to be gathered, and they have to be able to compile all that, because if you are missing critical pieces of information, you may or may not be able to determine that there’s coverage.

So sometimes carriers will say,”Hey, we’re still investigating.”That’s going to take some time to do that.

And if that’s the case, one of the questions that I would always ask you to ask is, what documentation do you need, and what is the focus of that investigation?

What things are you looking for?

Because as the insured, you may be able to help them get that information.

Remember, your goal is to provide them with the documentation to pay the claim.

And when you think about a denial, a denial is not necessarily the end if you get one.

It’s the beginning of a conversation, particularly if you understand why they’re denying it, and you have specific reasons that you can push back and ask for clarity.

At McGriff, our job is to help you understand the denial, and when appropriate, advocate for you when the insured does not get it right.

One of the things that comes up, and it’s kind of a technical term, but we talk about the insurance policy as a policy of adhesion.

Sounds kind of technical, but what a policy of adhesion means is that’s a contract that one party really doesn’t have any say in it, and that’s you as the insured.

The insurance company knows what’s in it, but you don’t necessarily have any say.

Why is that important?

The reason why that’s important is because if it is gray under the rules or the thought process of a policy of adhesion, if it’s gray, you as the policyholder should be given the benefit of the doubt.

And remember, one of the things I’ve said is that if it’s black and white in the policy and it’s clearly denied and it’s clearly not covered, that’s going to be very difficult to argue.

However, if it’s gray, maybe they don’t have enough information, maybe they don’t fully understand the law, so we can actually push back on that and ask them to reconsider that denial.

Another thing that has come up, kind of a question is, well, I have insurance.

Why don’t they just pay it?

Well, insurance doesn’t actually cover everything.

That’s why those exclusions are so important.

One of the examples that I would give is think about car warranties.

You go buy a new car, covers everything, right?

Because you got a new car.

Not necessarily.

If you don’t maintain it and you have a failure, it’s not covered.

If you’re involved in an accident causing damage to the car, it’s not covered.

Commercial policies work along the same lines.

You have exclusions and you have things that are clearly covered.

So always remember that there are things that are excluded and things that are covered.

If an insurance company wrote a policy, hypothetically, that covered every single thing, we probably would not be able to afford it.

So let’s move into commercial auto policies, which will be our first line of coverage.

So commercial auto policies are written on what is called an ISO form.

And what the ISO form is, is it stands for Insurance Services Office.

They actually define and write the overall policy language in many policies.

Most insurance companies don’t write it.

They’ll use an ISO form.

And what are the components of that?

Well, the components of it are very similar to what you see in a personal auto policy.

You would have your liability, your physical damage, your uninsured motorist, and medical payments.

The thing that actually makes a commercial auto policy different than a personal auto policy is it’s far more flexible.

It allows you to do things, and it gives you broader coverage than you would typically see in a personal auto policy.

So let’s start with liability.

This is similar to your personal auto policy.

You’ve got bodily injury, you’ve got property damage to third parties, and you’ve got defense cost, and that falls under the duty to defend.

If somebody files a lawsuit against you due to a commercial auto accident, insurance companies have a duty to defend, which means they will assign an attorney to defend you in that lawsuit as a result of that accident. thing commercial auto different personal it’s far more flexible.

It allows things, it gives broader coverage typically policy. start liability.

This similar You’ve bodily injury, you’ve property damage third parties, defense cost, falls under duty defend. somebody files lawsuit against due accident, companies defend, which means they will assign attorney defend result accident.

Physical damage follows along just like it would in your personal auto policy.

You’ve got collision, you’ve collided with another vehicle.

You’ve got comprehensive, sometimes called other than collision.

You struck an animal, falling objects, hail, things like that, that fall outside a collision claim.

You have underinsured and uninsured motorist as well as medical payments.

Physical follows along collision, collided another vehicle. comprehensive, sometimes called other collision. struck animal, falling objects, hail, that, fall outside collision claim. underinsured uninsured motorist well medical payments.

That’s your first party protection for insured and occupants of the vehicle.

And then you have hired non-owned liability for leased, rented, and employee-owned vehicles.

So I talked a little bit about the commercial auto policy being a little bit different and offering a wider variety of coverage.

And this is where your coverage symbols come in.

On your typical personal auto policy, you have whatever vehicles that you own, one, two, three vehicles, and they’re named out.

That’s first party protection for occupants then hired non-owned liability leased, rented, employee-owned vehicles. talked offering wider variety coverage. this where symbols in.

On typical policy, whatever vehicles own, vehicles, named out.

You have your VIN number, the year, make, model, and all those things, and those are specifically the covered vehicles on your policy.

Commercial auto policy works just a little bit differently.

We have symbols.

And there are a variety of symbols, but I’m actually going to touch on some of the more common ones.

And this is not meant to be comprehensive.

This is just meant to give you a little bit of an overview.

Symbol one is really the symbol that I like to see when we have a commercial auto claim because it defines any auto.

So any auto that’s being used in the course and scope of your business is actually going to be a covered auto.

VIN number, year, make, model, all specifically covered Commercial works differently. symbols. symbols, touch some common ones. not meant be comprehensive. give overview.

Symbol symbol claim because defines auto. used course scope business Symbol two is going to be owned autos only, vehicles that you actually own as your business.

Symbol number seven is going to be specifically described autos.

Symbol eight, hired autos only.

Symbol nine is going to be non-owned autos only.

And then we have a special symbol called symbol 19 that’s mobile equipment that actually has to carry insurance for road use, but is not primarily for road use.

So think about bulldozers, backhoes, something that you’re really not driving on the road on a regular basis, but you may need to drive from one side of the road to the other.

So sometimes you’ll have that come into play.

Again, this is not meant to be comprehensive.

It’s really meant to show you that there is a flexibility in commercial auto policies that’s a little bit different than personal auto policies.

So what are the exclusions that you see?

And we’re going to cover these a little bit more in detail in the next slide.

You’ve got intentional or expected injury, workers’ comp, unauthorized vehicle use, pollution exclusion, racing, and competitive exclusions, as well as late notice.

So let’s talk about that.

So top reasons you typically see commercial auto claims are denied.

Well, number one, the vehicle is not a covered auto under the policy, it doesn’t fall under any of the symbols, and it’s not on the schedule.

That’s fairly straightforward.

But could that be gray?

Yeah, sure.

Maybe you just bought the vehicle yesterday and it was involved in an accident today.

You sent for it to be added to the policy, and they haven’t done it yet.

So again, that’s something where you may initially get a response from the adjuster, but it’s not covered.

You have a driver that is not given permissive use to drive the vehicle.

So for insurance to follow a vehicle, you have to have somebody that’s allowed to drive it.

If somebody takes your vehicle and they did not have permission to use it, then that’s typically going to be excluded.

Anytime you have intentional acts, if somebody deliberately causes an accident, if I take my car and I run it into somebody because I’m upset with them, that’s an intentional act.

It’s not an accident.

And remember, your commercial auto policy is meant to cover accidents.

Employee injuries are typically going to be covered under workers’ comp, with some exceptions.

Pollution is not going to be covered if you have pollution cleanup, maybe from a spill from a trailer from hauling chemicals, unless you have an endorsement.

Racing and stunt use.

If you’re actually using your vehicle for racing, that’s a higher risk.

They’re obviously not going to cover that.

That’s going to fall under exclusion.

That is going to bring about a denial.

We talked about late notice at the very beginning.

You need to make sure that you are timely notifying the insurance company anytime there’s an accident because they need time to investigate it and gather information.

A lot of times, that information, the sooner that the insurance company can get it, the better off we are to gather everything and make sure that we have the file documented for it to be paid.

If you don’t notify them of a lawsuit, they surely are not going to defend you because they have to be able to answer that and make sure that they have everything in their file that they need to defend that.

They’re obviously that. exclusion.

That bring denial. late notice beginning. make sure timely notifying anytime there’s accident time investigate gather information.

A times, information, sooner better off everything file documented paid. notify them lawsuit, surely able answer their We’ve talked about newly acquired vehicles.

If you materially misrepresent anything in a policy, if you’re not honest, they can use that for grounds for a denial.

And named driver exclusions, sometimes that will come up.

Maybe you have employees that drive your vehicle, and maybe you have one particular employee that has a really bad driving record.

We’ve newly acquired materially misrepresent anything you’re honest, grounds driver exclusions, up.

Maybe employees drive vehicle, particular employee has bad driving record.

Maybe their license was revoked for whatever reason.

You may not want them driving your vehicle.

So the insurance company may come back and say,”Hey, we need you to exclude that driver.”So if I’m that excluded driver because of my bad driving record and I say,”Hey, I’m going to take the company car and I’m going to go get lunch,”or”I’m going to run this errand, I’m going to go see this client.”If I’m an excluded driver and you let me drive that vehicle and I’m involved in an accident, that’s typically not going to be covered.

And then the last item here is the status over is it a hired vehicle? license revoked reason. may say,”Hey, exclude driver.”excluded record take car lunch,””I’m run errand, client.”let me vehicle involved covered. last item here status over vehicle?

Is it covered somewhere else?

Is it a non-owned vehicle that’s not really a symbol on the policy?

And if you fall outside where vehicle coverage is.

This is kind of interesting because most people think that if I have a vehicle owned in the United States and I use it in the United States, let’s say I use it for travel, it’s going to be covered everywhere.

It is in the United States and Canada.

Most policies specifically exclude Mexico.

And a lot of times we will talk to clients, and they just assume since you can drive to Mexico, it may be covered.

In most policies, you’re actually going to need a specific endorsement to have that type of coverage.

So again, you need to read the policy, and you need to understand it.

So before we move on to the next slide, I’m actually going to talk about a claim scenario.

We talk about things being black and white in the policy or gray.

Now, I know that you can’t answer this because I did set this up for a poll, but I’m going to give you a scenario, and I’m going to ask you just for a brief moment to think about your initial reaction.

Now, to be fair, I haven’t given you guys a copy of the policy, and at the very beginning, I told you, you need to be able to read the policy.

So truly, you need to be able to read the policy to answer this, but I just want you to give me your initial reaction.

So I own a company car.

I take the car home.

I’m allowed to take it home from work.

That’s my normal vehicle, and I’m allowed to use it for personal use.

My wife actually drives the company car, and she’s involved in an accident.

What’s your initial thought?

Is that covered or is it not covered?

So since I’m the person that actually is assigned the company car, most people say that’s typically not going to be covered.

Well, some cases it is, and some cases it isn’t.

When I had a company car, the way the policy language was written, and we actually all read it, so we would understand it is, I was allowed to drive the company car for business use as well as personal use.

My spouse was allowed to drive the company car for personal use.

So she had full access to the car.

That was the way the policy was written.

However, my son, who was driving license age and had his driver’s license, was not allowed to drive the company car.

So should a claim scenario come up that involved an accident, my son would not be covered because he’s not covered under the policy.

However, there was additional carve-out under this particular policy that said my son could actually drive the car if there were an emergency.

My spouse allowed use. she had full access car. way written. son, who age driver’s license, scenario up son additional carve-out could emergency.

So if I were at home and I had a medical emergency and that was the only car available, my son took me to the hospital, and he was involved in an accident.

In that particular case, it could have been covered.

The reason why I give you that scenario is so that you can understand sometimes, depending on the circumstances, it would be covered, and sometimes it would not.

So how do you contest commercial auto denials?

Well, let’s start with the reservation of rights. home emergency only available, took hospital, he In case, been sometimes, depending circumstances, covered, not. contest denials?

Well, reservation rights.

We haven’t talked about reservation of rights letter, but let’s talk about what it is.

A reservation of rights letter is when the insurance company sends you a letter that says,”We are continuing to investigate this claim.

However, there are concerns as to whether or not the claim would be covered because of,”and they will cite specific policy provisions.

So a reservation of rights letter isn’t necessarily a denial letter, but what it is it’s a notification from the insurance company that they haven’t accepted the claim, but they haven’t denied the claim.

However, they’re letting you know that there are some concerns with the claim.

So if you get a reservation of rights letter, you’ll want to know what they’re talking about, what their concerns are.

If you get a denial letter, again, you want to understand exactly what the policy provisions are.

So if you have an insurance adjuster that says,”Hey, I don’t think this claim’s covered,”we don’t just want it verbally.

We actually want it in writing.

And I have had adjusters tell clients and insureds,”No, I’ve looked at this, and it’s not covered.”Well, can you provide us that in a denial letter?”No, I don’t think we’re going to send a denial letter.

I’ve just looked at it, and it’s not covered.”Well, why are we asking for a denial letter and a reservation of rights?

Because we want to be able to take that, and if we’re going to build our argument, we want to look at exactly what that policy language is, and we want to compare it to our actual policy and say,”Hey, does this make sense?

Is there room to argue this?

Is this something we can push back on?”So make sure that you get that in writing.

So once you have that, you want to make sure that you’re looking at all of the facts of the policy.

If there’s anything that is not correct in their investigation or their understanding of the claim, you want to respond.

You want to provide it in writing, and you want to make sure that it’s documented.

That becomes a permanent part of their file.

And you want to make sure that is all tied in with the policy provisions.

So you’re making sure that your rebuttals track with what is exactly in the policy language.

And again, that needs to be in writing.

Just like you asked for them to provide it in writing, your rebuttal needs to be in writing.

Now, if it involves a suit, and this is getting a little deep, I want to paint more with a broad brush, but I did want to point this out.

If it involves a suit and you’ve got a reservation of rights, and the carrier’s not sure if it’s covered or not, the way most policies are written, they can still provide a defense while they’re continuing to investigate.

So since suits typically are going to involve some type of time response, you want to make sure that if there’s a reservation of rights, you’re coming back to the carrier, and you’re asking for them in writing to provide a defense while they continue to investigate the claim.

The other thing is we want to make sure that we are understanding that if there are auto denials, that we’re looking at whether it’s a true coverage issue or whether it’s a valuation issue.

If a carrier accepts coverage under commercial auto, but there’s some type of dispute over what, let’s say, the value is of the total loss, there are mechanisms in place within the policy you can address that. understanding looking whether true issue valuation issue. carrier accepts auto, type dispute what, value total loss, mechanisms place within address A coverage dispute is going to be a little bit more involved simply from the standpoint of they’re looking at it from the perspective there may not be coverage at all.

If you’ve got coverage and you’re talking about purely a valuation issue, that’s a totally different scenario.

So valuation issues, let’s talk about that, how you contest that.

Most policies have an appraisal clause.

So if we’re talking about, and this comes up a lot in vehicle total loss.

If you have a total loss and the insurance company says, let’s just say they think the car is worth $20,000 and they’ve done their market research, and you think the car is worth $25,000.

They don’t want to budge, you don’t want to budge.

You both are confident in that number.

So how do you get past that?

Most policies have an appraisal clause, and the way that appraisal clause works, and you can invoke it as the policyholder, is you can select your own independent expert.

You pay for that.

The insurance company selects their own independent expert, and then they select a third party.

Both of the experts on the insurance company side and on your side do their own valuation for what they think the vehicle’s worth.

They submit it to the umpire, which is typically the third party that everybody agrees on, and they give a decision.

Now, the appraisal clause works because if you can’t bridge that gap, it allows you to have somebody come in.

It allows you to argue your case on what you think the vehicle’s worth.

Here’s the catch to the appraisal clause.

If you read the policy, most policies say that’s binding.

So if the insurance company says it’s worth 20 and you think it’s worth 25, it goes through the process, it comes back at 20 $20,000 could be the value of the vehicle.

So you could win it, you could lose it.

But that is the appraisal clause and how it works.

So they want to make sure that they are looking at valuing the claim properly.

You want to make sure the other thing is, as far as claims handling timelines, make sure you understand what the expectation is.

Carriers have an expectation to investigate claims timely and provide timely responses.

So you need to be keeping your own claim file, particularly if the claim is more complex.

When you reported it, documents that are in that claim file, if you have the insurance adjuster that’s saying they’re going to get you a response by the end of September, make a note, follow up with them at the end of September.

They need to make sure that they are promptly moving the claim forward.

If there’s a reason they can’t move the claim forward, lots of times it’s because lack of documentation.

Ask what they’re lacking.

See if you can help them.

Again, if I wear my adjuster hat, what I’m looking for is I’m looking to get everything that I need to pay this claim, and I can close this claim.

Because as an adjuster, a closed claim is the best type of claim to have because I can move on to something else.

If you have a situation where you’re not getting clear responses from the carrier, you’re not getting follow-up, and they’re not clearly communicating where they are in the process, that’s when you need to escalate it.

So, from an insured side, you may need to call a claims manager.

Sometimes you can report it to the Department of Insurance.

If it’s a policy, obviously, that we’re working on the McGriff side, you can reach out to us as well, and we can assist you with that.

So commercial auto, we talked about duty to defend.

It’s a little bit broader than paying the claim.

This is just kind of a recap.

We’ve got reservation of rights.

You need to understand what that means.

It’s not necessarily a denial.

We are expecting our carrier partners to do a reasonable investigation, make timely decisions, and offer a fair settlement.

Carrier has to be able to outline their position, not only in the settlement, but if there are specific coverage issues, they have to be able to tell you what those are.

They’re not going to keep those secret, but they should keep you up to date.

So what do you need to do to make sure that you don’t find yourself in a situation where a claim could potentially be denied?

Make sure you’re reviewing your policy every renewal.

Make sure you’ve got the right vehicles on there.

Make sure that if the vehicles that you’ve used or not using are non-owned vehicles or hired vehicles, you’ve got coverage for that.

Make sure you’ve got the right drivers.

Make sure you’re looking at your policy and understanding what it covers.

If there are any gaps in your policy, go back and make those changes.

Make sure that you have a process in place for adding new vehicles, reporting any usage changes, and make sure that you have one person that is dealing with the claim.

If you’ve got five or six people on the client insured side that are dealing with the claim, it can sometimes delay the flow of information.

So make sure you’ve got somebody that’s reporting it, they’re following up, they’re getting all the documentation over to the carrier as it’s requested, and they’re funneling everything because that’s going to make the claim go faster.

Make sure that if the claim becomes complex, if it’s a very complicated auto accident, there are a lot of moving parts, and there are things that could become challenging, that you’re aware of that right up front.

On complex denials and where you’ve got duty to defend situations because it’s become a very complicated accident, if appropriate, get your claims advocate involved.

Make sure that you are communicating those things, because the more complicated it is, the more in tune you need to stay with what’s going on and staying on top of it.

The thing that I tell people about claims is that an insurance carrier is going to do their best to handle the claim as efficiently and promptly as possible.

But at the end of the day, you as the client can’t be hands-off.

You have to make sure that you stay involved.

You have to know where they are in the process, what the next steps are, and sometimes you have to be your advocate as well.

So let’s move to commercial policies.

So commercial policies have a couple core coverages.

You have the building coverage, which is the property itself.

Business personal property, which is typically going to be your contents.

Business income, if for whatever reason that business is or if that building is down due to a fire, can’t be used or whatever, and you have extra expense.

Extra expense would be you have to go rent a warehouse because your warehouse burnt down.

Anything that falls outside your normal day-to-day expenses.

You have several cause of loss forms.

You have basic, broad, and special.

What are those?

A basic loss form, it’s typically going to be used on an older building.

It’s going to cover lightning, explosion, vandalism, and smoke.

What does it usually not cover?

Usually doesn’t cover theft.

It doesn’t cover weight of snow or ice.

Doesn’t cover water damage.

So you’re going to see that typically on older buildings.

That’s why it’s called basic coverage.

Broad coverage covers everything in basic, but it’s going to add back water damage, falling objects, ice, snow, and collapse.

So your special form is actually going to cover most losses with a couple exceptions.

So it’s going to cover everything basic and broad, typically does, but it’s actually going to exclude earth movement, flood, and utility services disruption.

Also would typically exclude ordinance and law.

What is ordinance and law?

Ordinance and law is where if you have to rebuild a building and the ordinance has changed or the code has changed, and so now it’s going to cost you, let’s say, $20,000 more when you rebuild due to an electrical code change that took place.

That actually would fall under ordinance and law, and you can actually pick that up as an endorsement.

What an endorsement is, is an endorsement is something that changes the policy in a material way.

So as an example of that, flood or not flood.

Let’s just say ordinance or law is a better one.

That’s typically going to be excluded.

You can go back and add an ordinance or law endorsement so that if your vehicle was damaged or destroyed and had to be rebuilt, it would pay for those additional costs.

So what do we see as common exclusions?

Well, flood is typically excluded.

Any type of water movement, storm surge, any type of earth movement, you’re going to see those are going to be excluded items.

Wear and tear, building deterioration, rust, corrosion, long-term maintenance issues.

Remember, the thought of the commercial property policy is you’re focusing on things that are unexpected.

It’s really a loss.

It’s an occurrence.

It’s something you couldn’t anticipate.

If you don’t take care of your building and you’ve got long-term maintenance issues, that’s not really an insurance policy thing that should be taken care of.

It also is not going to cover your fault through workmanship, construction, or design.

Ordinance of law, we’ve talked about.

It is surprising to me how codes will change, how expensive it can be, whether it’s electrical, whether it’s plumbing, whatever the case may be.

So if you’ve got a building, particularly a high-value building that may be slightly older, you need to make sure that you’re reviewing your policy and you have that endorsement in there if you think it would be appropriate.

Mold, fungus, bacteria, pollution, those are all things you can control.

If it’s something you can control, if you walk in your building and it’s got mold everywhere, you need to be able to take care of that.

That’s not necessarily an insurance claim.

Anytime you have utility services failure off premises, that’s not going to be covered.

There are certain property that’s not covered.

If you happen to have a business owner that collects, I don’t know, let’s just say, really expensive art, that may not be covered if you have a commercial property loss.

And we talked about flood and earth movement.

That’s not covered.

The main thing is, and this is kind of a recap of what we just talked about, the main thing is you need to understand what’s covered and what’s in the exclusions.

And again, if you’re looking at property claims and why they’re denied, is it in black and white in the policy?

We know flood’s not covered.

We know earthquake’s not covered unless that is written on a separate policy.

As far as physical loss, you have to have a physical loss to support business income.

So you can’t necessarily claim loss of business income or extra expense if you don’t have an occurrence or a loss to this building.

Where this actually really came into play that people didn’t understand this in the policy was actually during COVID.

You all may or may not remember, there were a lot of businesses that were shut down during COVID.

It was a very unique situation.

We’d never had anything like that come up before.

And because of that, people were claiming business income.

It actually wasn’t covered because there was no physical loss to the property.

And that was something we all learned as we went through the process.

And these other things, of course, we just talked about.

But as far as overall denials for property claims, we need to make sure that if there are specific gaps in documentation or the carrier interpretation of the policy that we’re looking at that.

Where came into play didn’t during COVID. remember, businesses shut down unique situation.

We’d never before. claiming income. wasn’t no physical loss property. something learned went process. these course, about. overall denials specific gaps documentation And that’s where you get the pushback.

The common theme throughout all this is anytime you’re pushing back on a denial, don’t assume just because the denial sounds very specific with the policy language, it’s actually correct.

Let’s go back and review it and make sure that we agree with that denial.

So we’re going to make sure, just like this, you will sometimes have the appraisal clause, much like in commercial auto, that you can use. pushback. theme throughout pushing assume sounds language, correct.

Let’s review agree sure, this, appraisal clause, much Again, that comes to the amount of loss, not the actual coverage.

Make sure that you are cooperating just like you would on the commercial auto policy.

Your documentation has to be in place.

It has to be done timely.

Sometimes carriers will ask you for a proof of loss, which will ask you to document the exact amount of the loss.

You will have to sign that.

A lot of times it has to be verified, so they’ll ask you to send that in notarized.

Again, comes amount actual Make cooperating Your place. done timely.

Sometimes carriers proof document exact loss. sign verified, they’ll send notarized.

It’ll ask you to send that in.

Make sure you review that and make sure that it’s accurate.

If you’re waiting for estimates, contractor estimates, or you’re waiting for additional information, make sure the carrier knows you need to have extra time and that you’re on the same page getting that in.

You don’t necessarily want to submit a proof of loss if it’s incomplete, because that’s not going to help you.

If it’s a complex loss, it involves structure collapse, it involves anything that you would need to engage an engineer, let’s address that early on because the insurance company’s going to bring out their engineers.

It’ll accurate. waiting estimates, contractor knows extra same page getting necessarily submit incomplete, help you. complex involves structure collapse, engage engineer, early company’s out engineers.

You may or may not agree with that.

It may be in your interest to hire your own engineer, because if you disagree with their position on it, you need to be able to push back.

And pushback has to be more than,”Hey, I disagree with that.”You need to be able to come back and say,”I’ve talked to our engineers, here’s our report.

Let’s sit down and work this out.”So make sure that your document production is consistent.

You’re giving them what they need.

Again, this goes back to cooperation.

Make sure you’re getting it timely.

On property claims, if you’re talking about business income, insurance companies use forensic accountants.

Their job is to go back and document exactly what that business income loss would be.

You can do that as well.

There are many policy provisions, not all, but many policies will offer a provision that the insurance company will pay for you to get your own forensic accountant to work through that.

And again, that’s something that you need to make sure that if that is offered under your policy, that you’re using it.

Bottom line is, if you don’t know what’s going on in the claim, you need to make sure that you’re talking to the adjuster and say,”What are you missing?

What do you need?

What can I do to help you?”Throughout this entire process, whether it’s workers’ comp, it’s auto, or property, remember, our goal is not to be adversarial.

Our goal is to ask the questions to make sure that we’re getting the information that we need to move the claim forward.

So key things to understand here.

There are some situations where you can have concurrent causation.

You have multiple things going on that contributed to the loss, and what that means is you got multiple causes of loss.

Some of them may be covered, some of them may not.

Sounds a little complicated, but what does that look like in the real world?

Well, let’s say you have an earth movement situation, and that’s excluded under the policy.

So you’ve got damage to your building, and it’s earth movement.

Well, we know that’s a clear exclusion.

Well, you might actually have an additional loss that due to that earth movement, it actually broke a natural gas line.

That natural gas line actually caused a fire.

Now you got fire damage.

So you got part of the claim that was excluded, it was earth movement, but the subsequent loss may have been damage due to a broken gas line.

Again, gets a little bit deep, but we want to cover it from a 30,000-foot view.

We just need to understand exactly what the exclusions say and what’s covered under the policy.

Cooperation is key, and again, if you feel like ordinances law is something that you need if you had to rebuild, make sure you’re looking at that coverage and making sure it’s there.

So documentation, pre-loss, just like in commercial auto.

Make sure that you understand what’s covered and what’s not.

You want to make sure that you understand what your obligations are.

Prompt notice, sending in the documentation, proof of loss, and cooperation with the investigation.

Again, we want one person, if possible, kind of overseeing this whole process from the insured standpoint.

Take photos.

Make sure that as soon as possible, you get photos.

Video also helps because if you’re the first person out there, you can preserve that through photos and videos.

Make sure you write down timelines and make sure you’re keeping a clear documentation of what the operational impacts are to your business because those all come into play on your claims.

And again, make sure that we’re engaging engineers and accountants early on if we feel like that’s something that’s going to be needed.

So now we’re going to move on to our final coverage area in workers’ compensation.

So when we move to workers’ compensation, let me explain why I included this.

Workers’ comp is a little bit different than the other policies that we talked about, that most of the time with what you’re dealing with, with workers’ comp, is you’re dealing with an injured worker.

The injured worker is primarily one involved, but the reason why I wanted to include this is a lot of times if you get a denial for workers’ comp, as employer, you think,”Well, is there any recourse to that?”So my goal here is to really provide you with some background of what can be done if your injured worker has a workers’ comp claim that’s denied.

Maybe they don’t agree with that.

Now, let me make one important caveat here.

You’re not really here to handle the claim for your employee.

You’re not really here to provide advice to them regarding handling a claim.

As an employer, your job is to report the claim, but I’m giving you background information.

There are things in place in each state.

They have people, ombudsmen, and other people that can help answer the employee’s questions, but I want you to understand what’s going on in the background so you’ll know that there is a process for that.

So what’s workers’ comp and what makes it different?

Well, we talked about the other two policies, commercial auto and commercial property.

They’re mandated by what’s actually in the policy form itself.

Workers’ comp’s a little bit different.

It’s state mandated.

You don’t have a quote policy per se, but you do have state statutes that are in place, and that’s going to vary.

So I’m talking kind of big picture here, but that’s what the workers’ comp framework’s going to look like.

What that individual state says is covered, not covered, and what circumstances would need to be met in order for it to be a workers’ comp claim.

Reason why workers’ comp’s out there, it’s a no-fault system.

They need to only show that it arose in the course and scope of employment.

Sometimes you’ll see the terminology AOE or COE.

That’s arising out of employment or in the course of employment.

So it has to be related to work.

It’s typically considered an exclusive remedy.

Those benefits generally take the place of filing a lawsuit against their employer.

Now, depending on the circumstance of the claim, they could bring a separate action, but we’re just talking big picture.

Most of the time, they’re going to go to workers’ comp to recover for the things that they’re owed from the injury.

What are those benefits?

Well, workers’ comp pays for medical.

It pays for temporary disability, temporary total disability when they’re out of work permanently or they can’t work for a period of time.

It pays for temporary partial disability.

Maybe they’re working part-time two days a week.

PPD is permanent partial disability.

They’re not able to return to work, or they may have permanent disability where they’re just not able to return at all.

Again, those are acronyms you may hear, but the bottom line is it pays for benefits when the employee cannot work.

So there is another aspect of workers’ comp that I’m not going to get real deep into, but it’s called employers’ liability.

Employers’ liability doesn’t necessarily cover the core benefits of workers’ comp we talked about above.

But what it does deal with is where you have a situation where there are questions as to whether or not the employer put an employee in a particularly difficult situation that could have caused harm.

They’re very rare.

You don’t really need to know a whole lot about it, but you do need to know that there are employer liability coverage under your typical workers’ comp policy.

Just like the other policies we talked about, you’ve got certain guidelines that you have to meet.

You have to notify the insurance company timely.

You need to make sure that you’re following their processes, which typically is going to mean going to the doctor that they direct you to.

Some states will allow them to choose their own doctor.

But there’s a process in place, and you need to make sure that you’re following through, or the employee is following through and making sure that they understand the process.

The biggest thing I would say from a workers’ comp standpoint that we see as a challenge is a lot of times injured workers don’t understand the process.

If they haven’t had a workers’ comp claim before, they just don’t understand.

So what we want to do is we want to make sure that they are able to get in touch with their adjuster and they can ask those questions.

The sooner you can get the claim reported and get them in touch with the adjuster, the better off the employee’s going to feel because those questions can be answered.

Obviously, if they’re attorney represented, then the attorney’s going to handle that for them.

So what do we see as far as exclusions?

Well, if it didn’t arise in the course and scope of employment, that’s absolutely not going to be covered under workers’ comp.

There’s a difference between me actually falling at work versus me standing there because I’ve got bad knees and falling.

That may not be a work-related injury.

So you really have to investigate and understand why and how the injury took place.

Pre-existing conditions, sometimes covered, sometimes not.

Degenerative disease, sometimes covered, sometimes not.

That’s going to depend on the state.

Sometimes in some states, if you have a pre-existing condition or degenerative disease and the work injury aggravated it, it’s going to be covered, and it’s going to bring it in.

Sometimes it’s not.

Again, I don’t want to get real deep in that, but you need to understand that those things can come into play.

Intoxication, fighting, willful misconduct, those are typically not going to be covered.

If you’ve got a dispute, was it your employee?

Was it an independent contractor?

Did you get a certificate of insurance?

Well, depending on how the insurance adjuster views that, may be covered, may not.

Again, that’s part of providing information so the insurance adjuster can make that determination.

If you’ve got late reporting, you didn’t file it timely, that could also be a reason that the claim’s not covered.

This one, the last one also I want to talk about, non-cooperation comes up.

If an injured employee is supposed to go see a doctor and they got themselves to see a specialist, they just don’t like that specialist, they decide they don’t want to go.

In many states, they can not pay for further treatment simply because they are offering and they’re offering to pay for treatment, and they’re sending them to a specialist.

Now, there are ways in place that the injured worker could ask for another doctor, but they just flat out refuse to go for medical treatment, that could be grounds for denial of workers’ comp benefits.

So again, this is recap.

Already denied, not course and scope of employment, medical documentation doesn’t back it up, missed deadlines, late appeals, independent contractor status.

I want to touch on that one more time, because if you don’t know that they have workers’ comp insurance and you’re just really not sure, or maybe it’s a mom-and-pop operation, they got two employees, and they come to do work at your location, there is a possibility if they get hurt, depending on state, you may end up having to pay it under your workers’ comp.

Again, you just want to make sure that you’re asking the question, do you have coverage?

And you need to verify what that coverage is before just allowing somebody to work at your property.

Intoxication, safety rule violations.

Safety rule violations are interesting.

In some states, you can partially deny the claim.

In other states, you can take an offset where maybe they get a 10% reduction of benefits.

But the reason why I bring that up in particular is a lot of people think, well, if they violate the safety rules, then it should just be denied completely.

Not always the case.

We need to understand what the actual statute says in that state to determine whether or not it’s covered or not.

So how would you go about contesting a workers’ comp claim?

Again, this is going to be more employee-driven, not employer-driven.

But the injured worker would need to ask, why is it denied?

And they would need to make sure that the adjuster fully understands their medical background, their history.

If there are medical records that would clearly indicate that maybe that should be covered, they need to make sure they’re providing that.

Sometimes this gets a little contested, but sometimes the adjuster will ask for previous medical records, and a lot of injured workers say,”Why?

Why do I have to provide that?”Well, because the adjuster needs to know your baseline.

For them to be able to determine that, they need to go back and look at your records.

Again, same thought process applies.

They’re not looking to deny it, not necessarily.

They’re looking to connect the dots to make sure it’s something that should be paid.

Your injured worker needs to understand that there are guidelines in place that they need to make sure that they follow.

The bottom line on this is if they don’t understand, they need to ask the adjuster.

If the adjuster isn’t providing them with clear information, then they need to go to whoever the state ombudsman is, and they will help point them in the right direction as far as what their rights are.

So when it comes up as far as denials, what can an injured worker typically do?

Well, if there’s an independent medical exam that gives a particular view on what the injury is, in many states, the injured employee can ask for an independent medical exam.

They can ask for clarity as far as what’s expected, as far as full medical, maximum medical improvement, what can be expected as far as future treatment.

They have, through most states, the option to use independent medical experts if they really feel like it’s something that needs to be explored further with the carrier.

But the bottom line is, this gets a little more technical than maybe I need it to, but the bottom line is, just like under a regular policy, they have tools at their disposal that they can come back, and they can challenge that denial.

Let me give you a prime example of that, and this really is focused on the state of North Carolina.

If an insurance adjuster on a workers’ comp claim issues a denial, they have to send that denial to the injured worker in writing.

At the bottom of that denial, it says,”If you disagree with this denial, you can fill out this form, and you can send it to the North Carolina Industrial Commission.”All they have to do is fill out why they disagree with it.

They send it to the Industrial Commission.

The Industrial Commission will set things in motion to go back to the insurance company and say,”Hey, John disagrees with this.

This is why.”And then you have your right to contest that denial.

So that’s an example of North Carolina, but that exists in almost every state or something like it.

So we’ve gone through this.

It has to be in course and scope of employment.

Sometimes that maximum medical improvement, you need to understand what that looks like.

Maximum medical improvement, if I touch on that for a moment, what that means is the employee’s as good as they’re going to get.

They may not be back to 100%.

They may be back at 80%.

That can sometimes affect their ability to return to work.

So maximum medical improvement is a key point in the claim that you need to make a decision as an injured employee as well as their employer, how does that fit in them returning to work?

So that’s a cornerstone of the claim, need to understand how that works.

If they have permanent disability or total disability, that always comes into play. 100%. 80%. affect ability return work. maximum improvement key point decision injured employer, does fit returning work? cornerstone claim, works. permanent disability disability, always play.

And again, as you work through these, if there are particular questions that you have, reach out to your adjuster.

If you are a McGriff client, you can reach out to us, and we can talk you through these issues as well.

So what about our checklist?

Make sure, this is key.

If you don’t remember anything else about workers’ comp, make sure you report it timely.

You’ve got to get the claim in timely.

Make sure that you have investigation protocols in place.

You know what to do.

Hopefully, workers’ comp accidents don’t happen a lot, but if they do, you want to make sure that you have an accident checklist and procedure in place. again, these, questions have, reach adjuster.

McGriff client, issues well. checklist? key. remember else workers’ comp, report investigation protocols do.

Hopefully, comp accidents happen lot, do, checklist procedure You need to make sure that you’re getting witness statements, file it timely, file it as quick as possible, because number one, you want to get it to the insurance adjuster so that they can begin their investigation and understand what benefits are due.

Number two, and I talked about this earlier, the sooner you can get the insurance adjuster and the injured worker in touch, the better you’re going to be because they’ll be able to ask those questions that may be giving them a little bit of anxiety.

Make sure that you provide all the investigation information to the carrier when you report it, and make sure that if there are denials, you understand exactly what’s going on.

The main thing with workers’ comp is communication.

Communication is key back and forth.

You want to make sure that you’re talking to the adjuster regularly so that you understand what’s going on with the claim.

You want to make sure that your injured worker is talking to the adjuster regularly, so they understand what’s going on with the claim.

And this is something that I always tell employers, this is extremely important.

Hear this one thing I say about workers’ comp.

If you have an employee that is injured, call them.

Don’t let them drop off the radar.

The number one thing I heard from injured employees was,”I got injured, and I didn’t feel like anybody cared.

Nobody called me.

I didn’t hear from anyone.”You don’t have to get involved in their treatment.

You don’t have to get involved in their claim.

Just give them a call and say,”Hey, just want to touch base with you, see how you’re feeling.

Looking forward to you coming back to work.”You can even say,”Hey, want to make sure that you’re communicating with the adjuster and getting everything that you need from them.”You don’t have to get into specifics.

As a matter of fact, we don’t want you getting specifics, but we do want you to let the injured employee know that they still are important.

So reach out to them regularly.

Send them a card.

High-level overview.

So how are we going to contest denials?

We need to understand the statutory policy reasons for denial.

Again, we don’t want to be Hulk.

We don’t want to get mad.

We don’t want to be emotional.

We need to understand.

If the policy’s black and white, we’re going to have a hard time contesting it.

If there’s a little bit of gray, if the carrier doesn’t understand it, or the reasons they cite in the policy don’t make sense, then we can push back, and we can contest that.

Make sure that you’re using it from an evidence-first mindset.

You’ve got to maintain clear documentation.

Remember, everything follows a pattern.

You want to make sure that if you say this, you can back it up with documentation.

You can clearly say,”Okay, Mr. or Mrs.

Adjuster, here’s what I’m saying.”Make sure that you have a timeline tracking, you’re noting when you report the claim, and you’re keeping a log of everything going on.

You know when it’s happening, why it’s happening.

So if you need to come back and push on the insurance company and say,”Hey, I got an answer.

You told me you were going to let me know at the end of August, and it’s September 17th,”you’ve got those hard points in the claim documented.

There are tools at your disposal, appraisal, mediation sometimes comes into play.

We didn’t really talk about that, but sometimes instead of getting involved in litigation, you can use mediation.

And then you’ve got a bunch of administrative processes that can come into play as well.

Litigation is really the last step, because what happens when things become litigated?

They last a long time, and they don’t go away.

At the end of the day, we’re looking for compromise.

We want to get to a situation where we can get together, and we can say,”Hey, this will make us happy, and this will get this closed.”Understand coverage limits and make sure that you’re following post-loss duties so that you’re not getting a denial just because you missed something.

As far as your toolkit, make sure that you read the denial response.

Make sure you read the reservation of rights.

Pull out your policy.

Make sure you understand what it says.

Reach out to your claims advocate.

Make sure that they’re in agreement with what it says.

Understand where you can push back.

Documentation, we talked about the importance of that.

Have your preferred vendor list.

Hopefully, you won’t need them because you’re not having a lot of claims.

But if you do have a frequency of claims, particularly building claims, you need to make sure that you have engineers that you can use, forensic accountants, medical and vocational experts.

That’s really going to fall under workers’ comp.

May not need as much of that.

But the point is, you need a toolkit.

You need to know who’s out there that you can use.

Make sure that you have clear procedures in place for incident reporting, and make sure everybody on your team understands what their post-loss duties are.

So key takeaways.

Denials, they’re not going to be a surprise most of the time.

They follow predictable patterns.

If you sit down and you read your policy, you’re going to know what those patterns are.

If you haven’t read your policy, I challenge you to go read it.

You might be surprised at what’s in there, and you might think,”Hey, I didn’t know this was exclusion.

I may need to look at that.”Make sure you understand what your pre-loss response needs to be, and make sure that you understand all your expectations.

And remember, when you look at the denial, everything’s to be evidence-based.

You’re Bruce Banner, you’re not Hulk.

You need to talk about it logically.

If you call an adjuster and you just start yelling at them and say,”Hey, you need to pay this claim because I paid insurance with you guys and I’ve been with you guys for seven years,”it’s not really going to give them a reason to pay the claim.

However, if you call them and say,”Well, according to this exclusion, you didn’t interpret it properly, and based on this information that I gave you, this should be covered,”now you’re having a conversation.

Know when it needs to be escalated and understand that if there are particular challenging claim situations, we can help you coordinate that documentation and look at the policy, and we can provide you with strategic input on what next steps may be.

Now, that may be that, hey, the policy is clear.

We don’t know how we can push back against this.

Or, hey, there is some gray here.

I think if we take this particular approach, we may be able to appeal and push back on this denial.

That is all I have.

Does anybody have any specific questions?

Wow.

Thank you, John, so much for this wonderful presentation.

And I know that he covered a lot of valuable content, and everyone will receive a copy of the presentation slides as well as the recording afterwards.

But we do have a question that has come through the box.

It says: What about minor injuries like a laceration on the hand that may only require one or two sutures?

Do I have to call that in to the carrier, or can I just pay for it myself?

Yeah.

So that’s a great question.

And on something like that, if it’s on-site first aid, it doesn’t necessarily need to be called in.

However, but I would say this, if you think there’s a chance they may need further medical treatment, then yes, I’ll report that. question box. says: What minor injuries laceration hand require two sutures? call carrier, myself?

Yeah. great question. on-site aid, doesn’t say chance further treatment, yes, I’ll But here’s a neat option under workers’ comp.

First aid on-site, it needs a Band-Aid.

I probably may not do anything with that, but consider this, you can always report a claim as a record only.

So in this particular circumstance, you can say,”Hey, I’m going to send it into my insurance company.

I’m going to report it as a record only.”What does that mean?

What that means is the insurance company’s going to say,”Yes, this person cut their hand. here’s neat option comp.

First aid on-site, needs Band-Aid. probably consider only. circumstance, company. only.”mean?”Yes, person cut hand.

Maybe they got a couple stitches.”The employer could pay that out of pocket, and it says,”We really don’t expect any bills to come in.”That really is going to be a situation where you have to gauge whether or not you think there’s going to be medical treatment.

But if there’s not, and it’s on-site first aid, always remember that you have the option to report it as a record only, just so it is on file.

That would probably be the most conservative way to handle it.

Awesome.

Well, thank you so much.

That was the only question.

And in the future, if anyone has any additional questions, I will make sure John leaves his contact when we share the presentation slides as well as the recording. couple stitches.”employer pocket, says,”We expect bills in.”situation gauge treatment. not, only, file. most conservative handle Awesome. thank much. future, anyone questions, John leaves contact share presentation slides recording.

And so again, a special thank you to John for that wonderful presentation.

And on behalf of McGriff, I want to thank you all again for your participation, and please stay tuned for future webinars hosted by our group.

Thank you, and you have a wonderful rest of your day. special wonderful presentation. behalf McGriff, again participation, please stay tuned future webinars hosted by group.

Thank you, rest day.