intelligence, but also lends invaluable
hands-on guidance in the field to both
injured worker and employer alike. This
level of empathetic, hands-on service in
the field often serves as the critical deterrent against claimants immediately opting
to pursue their claims through litigation.
The potential of the AOE/COE
There is little doubt that there are a multitude of carriers, TPAs and self-insured/
self-administered entities that would benefit from the potential the implementation
of the AOE/COE approach yields. In addition to refining overall investigative processes in the field, this approach also serves
as a classic tool for proactive planning.
This approach could begin as an introductory service, offered to dedicated units in states outside of California,
which haven’t experienced its benefits
first-hand. Following the initial launch as
a pilot program, as demand for these services rises, the pieces would already be in
place to respond by gradually expanding
the service in markets through a hands-on training program, both internally and
in the field.
This demand would necessitate the development of a highly trained specialty
unit, which would serve as an example of
superior claims-specific customer service
to clients at contract renewal time.
How the process works
Ideally, the initial rollout of the AOE/
COE approach would specifically target
dedicated units charged with the handling of Florida-specific retail, hospitality
and manufacturing accounts for such entities, keeping in mind the impact of the
Castellanos ruling and all existing procedures currently in place for triage and
investigative services in the field.
A cost benefits analysis reveals that it
would yield very tangible and profound
client savings, specifically with respect
to allocated legal expenses. This targeted
approach to identifying and obtaining re-
corded statements from witnesses in the
field during the early stages translates di-
rectly into savings on the litigation front.
Consistent engagement in this meth-
od of informal discovery during this ini-
tial triage process enhances the ability to
identify and interview all witnesses in the
early stages, accurately gauging their rel-
ative knowledge levels. Once the case is
referred to defense counsel, the handling
attorney would be placed in a prime posi-
tion to only notice those depositions cer-
tain to yield quantifiable information with
respect to their overall defense strategies.
Further, the implementation of this ap-
proach frees up senior associates carrying
significantly higher than average quanti-
ties of pending files for potential training
of less experienced associates, increasing
the overall population of senior staffing.
Another prime advantage in AOE/
COE field investigations is the rapid
turnaround of the communication and
documentation they provide, relative to
identifying the manner of injury, specific
date or repetitive use, as well as the nature
and extent in the first 30 days.
Conversely, red flags in claims would
become more readily identifiable during
the initial course and scope investigation.
This would dramatically enhance the abil-
ity to notify SIU immediately by provid-
ing the initial reports along with defense
counsel where litigation is anticipated.
Chief issues would include but not be
limited to: evidence pointing to suspect-
ed non-industrial causation; pre-exist-
ing medical conditions; performance or
attitudinal issues, and the verification of
post-termination reporting of claims.
The reason for using Florida as a test
case lies in the timing to introduce this
platform based on data provided by local
auditors confirming that the ripple effect
of Castellanos and Wesphal is already tak-
ing hold there, and new petitions for ben-
efits filings are dramatically on the rise.
The industry’s response in dealing with
this new reality in Florida will necessitate
a renewed emphasis on swift yet compre-
hensive preliminary investigations, cou-
pled with an emphasis on compassionate
guidance in the field.
It is clear that the reversal of Castellanos
and Wesphal will result in an inevitable
and significant uptick in the frequency of
petitions for benefits in Florida, and one
way to get ahead of this development is
through the implementation of the AOE/
COE approach in the field.
This approach will not only aid in
identifying the nature, extent and com-pensability of any given claim in the early
stages, but will also serve as an informal
training mechanism for field staff.
Implementing the AOE/COE
Since these investigations are preliminary
and clearly independent of SIU, it makes
sense to develop this unit as a way to cross-train licensed adjusters, such as looking
for candidates who have received their
board certifications in Florida Workers’
Compensation (CWC) or are credentialed
in Workers’ Compensation Litigation
(“CWCL”) through the Florida WCCP.
Identified as “field representatives”
rather than “investigators,” they would
serve in a hybrid role as both field investigators and field adjusters, acting as conduits of enhanced communication within
Each case would provide an opportunity to share with employers and injured
workers alike the many tools available
that will ultimately prove invaluable in
their efforts to navigate the current Florida workers’ compensation system. This
level of dedication in the field will not
only yield prompt investigations, but will
also lead to organic training through consistent repetition.
The ability to respond in times of crisis
defines the leading edge of an industry.
This approach serves as an example of a
preeminent asset lacking in the current
Aaron Bergman, CWC, CWCL (aaron@
the owner-operator of Everglades Claims