Claim Mitigation & Investigation

Identifying “Red Flags” & Best Practice for Pre-Existing Accidents/Injuries. 

By: Michelle Namisniak

Managing the claims is one of the keys to protecting your business and controlling your insurance costs. Below are some tips from our OneGroup claims professionals on how to best identify “red flags” in claim management, as well as understanding how to best mitigate your claim costs or exposure practice for employees with pre-existing injuries or accidents.

If a claim is filed, investigate and gather facts to see if a prior injury or condition can be identified that may be a contributing cause of the new injury. Investigate and identify the following facts:

  1. The extent of the prior injury.
  2. If the prior injury was also work-related.
  3. When the employee was last treated for the injury prior to the new accident date.
  4. Gather names and contact information for all treatment providers.
  5. Obtain a signed HIPAA and request the prior medical records in order to consider:
    • Pre-injury status to see if a denial is warranted.
    • If there is any apportionment.
    • Accepting the claim as a temporary aggravation of a pre-existing injury, and stopping payment for medical treatment once the employee is back to baseline status.  

If an employee is unable to return to work in an established claim and their status is terminated, negotiate a full and final Section 32 settlement of the claim to reduce your exposure and dispose of the claim. Consider annuitizing the medical portion of the settlement for an approximate 30% savings of the medical spend.

Understanding these factors can positively impact not only the time frame of a claim and the rate at which healthy workers are able to return to their jobs, but also the containment of insurance premiums and healthcare costs and the maintenance of productivity in your workplace.

Our claims professionals will assist your team in all aspects of the claim process. From analyzing your operations and risk exposures, to reviewing what to report and advocating for choice of counsel, to monitoring reserves and engaging with the insurance adjuster, we work on your behalf to facilitate the best outcome.

Contact us

For more information please contact Brett Findlay, Vice President Business Risk Specialist at (315) 280-6376 or

This content is for informational purposes only and not for the purpose of providing professional, financial, medical or legal advice. You should contact your licensed professional to obtain advice with respect to any particular issue or problem. Please refer to your policy contract for any specific information or questions on applicability of coverage.

Please note coverage can not be bound or a claim reported without written acknowledgment from a OneGroup Representative.

Written content in blog post: Copyright © 2020 Applied Systems, Inc. All rights reserved.