What is the Role of a Workers’ Compensation Adjuster?

The role and status of an “adjuster” is similar in all insurance contexts. In general, an adjuster is a licensed insurance professional. His or her role is to apply the terms and conditions of an insurance policy to the facts and circumstances of a claim and the damages resulting from it. In doing so, an insurance adjuster both calculates and, in some cases, negotiates a dollar value or other policy benefit to be paid or allowed to the person or entity making a claim.

A “claim” is an occurrence that results in monetary damages to the person or entity insured under an insurance policy. A “first-party claim” exists when the insured is reimbursed for his or her monetary loss under his or her insurance policy. A “claim” can also be an occurrence that results in monetary damage to a thirdparty when the damage is caused or contributed to by the action or inaction (“negligence”) of the person insured under an insurance policy. That is called a “third-party claim.” An example would be that of an individual being hit by a car resulting in a spinal cord injury or some other catastrophic injury. The insured in that situation gets protected from monetary loss because the insurance company pays the thirdparty on his or her behalf, if the insured is found to be legally liable, and to the extent of available dollar limits of the insurance policy.

The definition of a “claim” that applies in a given situation depends upon the type of insurance involved. Monetary damages can be liquidated damages measured in money (such as the actual cost of repairing a car after a collision). The damages can also be unliquidated, such as the value of the pain and suffering that an injured individual experiences after a catastrophic injury. Unliquidated damages would also include compensation based upon a projection of the cost of rehabilitation, specialized rehabilitation, post-acute care, re-training in activities of daily living (ADLs) and those other aspects of care the individual needs in order to achieve independence and to achieve the best possible outcome after an injury. In either event, the damages may be negotiated, or determined by a judge or jury after litigation, or at any time in between.

Because insurance is an industry that is highly regulated, an adjuster must apply prevailing insurance law to the adjustment of a claim. The adjuster must also apply the law governing the type of occurrence that gave rise to the claim. Often, both are on the state level.

The role of a workers’ compensation adjuster has all of the attributes of any other type of insurance adjuster. But it has added characteristics that make it more complex. Those factors include:

• Workers’ compensation insurance has a well-defined statutory scheme of benefits. Although the benefit scheme may differ by state, the workers’ compensation law of the governing state dictates the specific benefits payable. The benefits generally include both the payment of medical expenses and at least a portion of lost wages;
• The “trade-off” that the employee and employer make for worker’s compensation benefits in lieu of litigation with the employer enters into the adjuster’s analysis differently than in a liability claim, where there is no such trade-off (see our blog, What is Workers’ Compensation?). That is, the threshold issues that the workers’ compensation adjuster considers are whether the individual was an employee at the time of the occurrence and whether the injury occurred within the course and scope of the employment. If the threshold is met, state workers’ compensation law largely dictates the benefits payable. Conversely, in a liability claim, the adjuster would also consider issues of comparative or contributory negligence, depending upon the law of the jurisdiction; employment status is rarely a direct issue unless a question of vicarious liability arises;
• Because the workers’ compensation insurer is given the right and power to control and to direct the medical care and rehabilitation of the individual, there is a more active and a closer degree of monitoring of the injured individual’s progress and rehabilitation. For example, a workers’ compensation adjuster may have input to the post-acute rehabilitation Client Goal Plan that NeuLife customizes for each client, and to the rehabilitation and specialized rehabilitation that is administered pursuant to it;
• The workers’ compensation adjuster is concerned with rehabilitation, getting the individual back to work through the provision of clinically relevant services designed to do so, and achieving independence to the extent possible. In contrast, a liability adjuster may be mainly concerned with assessing liability for an occurrence, negotiating the claim within his or her settlement authority or determining that litigation is a better route. The role of the worker’s compensation adjuster may, therefore, be considered to be more complex and to have more factors to balance and ends to achieve.

NeuLife’s philosophy is that healing, wellness and personal fulfillment are best accomplished in a positive and uplifting therapeutic environment where caring staff encourage, assist and support each client so he or she may achieve specific goals. NeuLife believes personal fulfillment is equally as important as goals to increase function and independence. NeuLife seeks to achieve maximized, sustained outcomes that exceed the expectations of all persons served.

NeuLife, in Mount Dora, Florida, is a fully accessible residential post-acute program providing specialized rehabilitation to individuals diagnosed with traumatic brain injury (TBI), spinal cord injury (SCI), traumatic amputations and other catastrophic injuries.

2725 Robie Avenue

Mount Dora, Florida 32757