As part of any initial investigation, the claims representative should always attempt to obtain a recorded statement from the claimant. It is obviously important as part of the initial determination of whether a claim is compensable or not. It is also potentially invaluable later if the claim becomes subject to litigation.
The first step is to obtain and/or verify identifying information for the claimant, such as their physical description, address, names of other persons living in their residence, vehicles driven, hobbies and other items. Ideally, these details will be irrelevant. But if the insurer decides surveillance of the claimant is necessary to verify or dispute their claims, this information will be crucial. The investigator needs enough evidence to locate the claimant and distinguish them from other similar-looking individuals.
For example, we recently had a case where the claimant moved residences after he gave his recorded statement. The information we collected allowed us to provide the investigator with a detailed physical description of the claimant and the truck he drove. Once the investigator located the claimant’s new residence, he was able to easily identify the claimant. He then obtained footage of the claimant performing remodeling work on a house while simultaneously informing his treating physician he could barely walk, could not bend and could not lift anything due to extreme pain. The surveillance video showed just the opposite, and we were able to use that surveillance video when we met with the claimant’s treating physician.
Prior to that meeting (and the doctor’s viewing of the surveillance video), the claimant had been recommended for shoulder surgery and lumbar spine injections. Following that meeting, the doctor released the claimant to return to regular duty work with no restrictions, and we were able to successfully close out the claim for a nominal amount.
Additional pertinent details
It’s important to obtain other information including details about the claimant’s job duties, work history and other aspects of employment, followed by key facts about the alleged accident/injury.
Consider another case that involved a school employee. The employee stated in her recorded statement that she twisted her ankle because a student ran out of the classroom and bumped into her. We were lucky enough to have security video of the incident, which showed she tripped over her own feet with no student in the vicinity.
When we presented the video to the claimant’s attorney, he responded that the adjuster must have misheard or misunderstood the claimant, and she did not say she had been bumped by a student. Rather, the attorney said, his client turned her ankle slipping on something on the hallway floor.
We then provided him with the recorded statement of the claimant, in her own words, claiming she was bumped by a student. The claimant’s attorney withdrew and dismissed the claim the following day.
Medical concerns
A final portion of the recorded statement should address the claimant’s medical treatment following the alleged injury and any relevant prior medical history.
We frequently see important differences in the medical records regarding how the claimant explains the injury to doctors. While this can be good evidence at a hearing, the claimant can always explain that the doctor misunderstood what they said. If we have a recording of the claimant’s own words describing the accident, we have very good evidence for impeachment and other purposes at the hearing if the medical records differ from the recorded statement.
Although the items we ask about and record are intended to be exhaustive, there are certainly other questions that may be relevant depending on the circumstances. For example, if the employee is alleging an injury due to repetitive motion, it will be important to ask questions regarding any outside activities that could cause the same symptoms. The more detail that can be gathered up front, the better the claim can be defended at the outset and going forward.
What follows is the basic identifying information that should be verified during a claimant interviews:
Full name (prior names/maiden names/aliases
Date of birth
Social security
Current address
email address
Cell phone number
Height and weight
Hair color and eye color
right or left handed
wear glasses and/or contacts
take any medications on a regular basis
other health conditions
doctor’s name
relationship status
spouses name
name and ages of dependents and grown children
highest level of education completed
military experience
languages spoken
prior insurance claims
prior lawsuits
hobbies
driving ability
vehicles driven
The claim representative also should inquire about the claimant’s work history — especially in a workers’ comp case. These questions should address:
A detailed work history
job duties for each prior position
reasons for leaving each prior job
job title with the employer
date of hire
detailed description of current job duties
does this job require any special equipment (i.e. safety glasses, hearing protection, etc.)
name of supervisor(s)
full or part time
work shift/ hours/ regular schedule
hourly wage rate
average hours worked per week
how long in that position
prior positions / job duties for the employer
other jobs or sources of income at the time of the injury
Details related to how the accident/injury occurred; day of the week/time of day
were medications, drugs or alcohol consumed in the 24 hours prior to the accident
witnesses to accident/injury
any video of the accident/injury
photos of the scene of the accident
did you report the accident/injury to anyone and if so when, to whom, what exactly did you tell them and what did they say.
Ask the claimant to describe in detail all body parts injured;
What was not injured
did you continue working/finish your shift
Were you scheduled to work the next day
When was the first day you missed work?
When did you return to work
Have you been offered any light-duty or modified work, and if so, describe in detail the job offered.
It also will be essential to gather information about the claimant’s medical history and treatment. Ask questions such as:
When did you first see a medical provider following this injury?
What exactly did you tell them had happened to you?
What did the medical provider tell you about your condition/injury?
How did you choose the medical provider?
Why did you choose that provider?
Are you familiar with the employer’s posted panel of physicians?
Where is it posted?
Was the purpose and function of the posted panel explained during your initial employee orientation?
Did anyone show you a copy of the panel of physicians following your report of injury?
Who showed you the posted panel?
What did they say?
Detail all subsequent medical treatment received.
What treatment (physical therapy, etc.) testing or medication has been prescribed for you?
Who prescribed it?
What medications are you currently taking (including medications not related to your alleged injury?
Has any medical provider assigned work restrictions?
What are they?
Have you communicated those work restrictions to the employer?
Who exactly did you talk to?
What did you tell them?
Have you seen any other medical providers since your injury?
Who is your primary care physician/family doctor?
What do they treat you for?
Any prior injuries to the body part(s) alleged to be injured in this claim?
All prior injuries
identify any prior medical providers
for each prior injury, provide a description of how you were injured, and the duration of medical treatment received and the identity of the medical providers.
…Did you undergo a pre-hire physical examination?
Did you complete a post-hire medical questionnaire?
If so, did you identify the prior injuries or medical conditions identified above
Describe your current symptoms in detail.
Is the pain mild, medium, or severe?
Is the pain constant or intermittent?
What activities aggravate or lessens your pain?
Describe a typical day for you since this injury?
Are there activities you could do prior to the incident that you are now unable to do?
Provide details.
Are you capable of performing routine household duties or yard work?
Do you have any work restricitions?
What do you feel are your physical restrictions?
Do you believe you are capable of performing your regular duty work?
If so, please explain what job duties you could perform.
Detail all communications you have had with the employer regarding your work status, your ability to return to work, and any other relevant communication with the employer.
Jim and Bonnie Grant
Get Help With Insurance, Inc.
223 S Water Street, Suite B
Henderson, NV 89015
(702) 541-0882