Ending Report Frustration

Far too often adjusters and claims staff lament insurer examination reports that are lengthy and difficult to follow. They are filled with irrelevant information that adjusters need to wade through and often lack appropriate and useful information.

As a starting point, the expertise of the assessor is critical in terms of not only ensuring accepted practices and information that will withstand scrutiny if challenged, but also regarding clear, concise and prompt reports. Qualified and experienced assessors will follow your direction by providing answers that directly correspond to each of your questions with recommendations, if requested, that are relevant and realistic.

To select the most appropriate assessor, be sure to check everything from their education, training, current license and area of specialty to practical experience and professional memberships, as well as authorships, research, and expert witness testimony experience. Once you have selected the most appropriate assessor, provide all documentation on file such as accident details, medical records, reports, and case notes. The pre-injury medical records and clinical notes are especially important for Minor Injury Guideline determinations. In addition to the background information, it is important to provide the assessor with a well-defined request that specifically outlines the type of information you need. With IEs, getting the right answers is often directly related to asking the right questions and requesting specific information.

The right questions, the right answers

The best way to avoid the frustration of receiving an IE report that is difficult to follow, lengthy and filled with irrelevant information, is to be very clear and direct in terms of the IE questions. Never assume that the assessor will know what you are looking for. Regardless of benefit category, here is an overview of question topic areas to include for all types of IEs:

• diagnosis

• prognosis

• pre-existing issues and their impact on injuries

• return to pre-accident status

• recovery to date

• recommendations regarding present treatment, its effectiveness and other treatment that would be beneficial, as well as suggested duration

• other comments pertinent to the case

While ensuring your questions cover all the basic topics listed above, it is important to be as clear and specific as possible regarding how you pose the IE questions and how you ask for specific information. To follow are some additional guidelines concerning possible questions to ask–and how to word them –related to different benefit categories and possible assessments.

Income Replacement Benefits: Possible assessments include worksite assessment, functional abilities assessment, transferable skills analysis, and vocational testing. Guidelines for possible questions include:

• Does the client have a substantial inability to carry out the essential tasks of his/her employment?

• Please precisely identify the limitations and restrictions preventing return to employment and comment on the objective findings that support these limitations.

• What type of work is the client capable of participating in?

• Please comment on the possibility of modified work and/or a graduated return to work.

Med-Rehab Benefits: Possible assessments include home assessment and assistive devices assessment, attendant care assessment, physiotherapy assessments, massage therapy assessments and chiropractic assessments. Guidelines for possible questions:

• Do you have any recommendations regarding the present treatment?

• Is the present treatment effective?

• Do you recommend any other treatments that may be effective? If so, please advise the treatment(s) you recommend and estimate frequency and duration(s).

• Are the recommended assistive devices reasonable and necessary?

Housekeeping benefits (optional): Possible assessments include home assessment and assistive devices assessment and functional abilities evaluations. Guidelines for possible questions include:

• Does the client suffer a substantial inability to perform the housekeeping/home maintenance services that he/she performed before the accident?

• Please precisely identify the limitations and restrictions preventing a return to housekeeping and home maintenance activities, and provide the objective findings that support these limitations.

• Please identify complications that may be prolonging the disability, preventing a return to housekeeping and home maintenance activities.

• If the client is unable to perform housekeeping and home maintenance activities, when is it anticipated that he/she will be able to resume them?

• Please provide recommendations to address the barriers (e. g. treatment, referrals).

Caregiver benefits (optional): Possible assessments include caregiver assessment, home assessment, and functional abilities assessment. Guidelines for possible questions include:

• Does the client have a substantial inability to carry out the essential tasks of his or her caregiving activities?

• Please precisely identify the limitations and restrictions preventing a return to his or her caregiving activities and comment on the objective findings that support these limitations.

• Please provide recommendations to address the barriers (e. g. treatment, referrals).

Non-earner benefits: Possible assessments include home assessment, functional abilities evaluation and attendant care assessment. Guidelines for possible questions include:

• Does the client continue to suffer a substantial inability to carry on a normal life as a result of the accident and within 104 weeks of the accident?

• Please precisely identify the limitations and restrictions preventing a return to his or her activities of normal living and comment on the objective findings that support these limitations.

• Does the client require the services of an attendant to manage or assist with activities of daily living?

104-week mark: Possible assessments include home assessment (for post-104 caregiver only), functional abilities evaluation, medical assessment(s), and vocational/psycho-vocational assessments. Guidelines for possible questions include:

• Does the client suffer a complete inability to engage in any employment for which he or she is reasonably suited by education, training or experience?

• IRB: Does the client suffer a complete inability to engage in any employment for which he or she is reasonably suited by education, training or experience?

• Please provide recommendations to address these barriers (e. g., treatment, referrals).

Cover all the basics; be specific

Taking control by providing clear and specific direction to the assessor goes a long way in decreasing IE report frustration. Qualified assessors will not only appreciate this highly organized, professional approach, in turn, they will mirror it by providing you with answers and recommendations that are highly organized and professional by directly meeting your requirements. The IE is definitely an example of where quality input leads to quality output.

Judy Farrimond is technical advisor catastrophic and legal services, and Ian Elliott is the national director of clinical services at Sibley & Associates Inc.