by John Godfrey
Retired jeweler and member, Retailers Mutual Board of Directors
Few policyholders realize how carefully the Retailers Mutual board considers and reviews each work comp claim. It is this process that enables us to be successful — settling claims efficiently and fairly, and disputing claims when warranted in order to control costs and discourage frivolous claims.
When an injury occurs, the employer files a report with Sedgwick Claims Management Services, our partner in processing claims. Our Sedgwick representative does the homework, collecting more information on the incident if necessary.
He provides a case history, including a recommendation, for each claim to the board’s Claims Committee about a week before the committee meets, allowing us time to review the claims and prepare questions.
The committee meets by conference call to review every claim, major or minor. If the claim is straightforward and the compensation will be less than $7,500, the committee can decide it; otherwise, it will go before the full Board of Directors, which hears the committee’s summary of the case before reaching a decision.
The committee will query Sedgwick about its recommendations, and sometimes we query attorneys as well. Sometimes we accept Sedgwick’s recommendations, but often we seek additional guidance on whether to raise or lower the award, or to do additional investigation before deciding.
We are not simply deciding whether the claim is valid or how much to award — we might also look for other partners in the claim. For example, after a slip-and-fall injury due to an icy walkway, we check whether the business owns the property or leases it, in which case the landlord might be a partner in a settlement or litigation.
The total number of years and experience on our five-member Claims Committee is very high. Most of us have served for 10 years or more and also have many years of retail and other business experience; a few are newer to the committee, gaining experience for when the older members leave the board.
For example, when a case is from a jewelry store, I might have questions about statements made in a claim, based on my experience as a jeweler. Others on the board have their own experiences to draw on. And all of us know the ins and outs of running a business. It is this practical experience with all types of business that enables our claims review to be thorough and fair.
Any insurance company can offer competitive pricing, but few others offer the unique combination of experience and understanding of work comp and small business in general that Retailers Mutual provides.