AUGUSTA – Some 1,122 people collected benefits for on-the-job injuries that kept them out of work more than a week this spring.
More than 780 had their initial benefit applications denied.
Officials say it’s too early to tell if that’s a healthy number.
The state has started to track when workers compensation injury claims are initially denied, out of concern that some insurance carriers here might be rejecting too many people too often.
The most extreme case in the second-quarter compliance report that was released by the Workers’ Compensation Board on Tuesday: Wal-Mart.
The retail giant approved four claims and rejected 87 from April to June. The company has a self-administered workers compensation plan under AIG insurance.
A spokesman for AIG said the company hadn’t yet seen the report and couldn’t comment. Wal-Mart did not return calls seeking comment.
“That’s a concern for us,” said Steve Minkowsky, deputy director of benefits administration, with oversight of the board’s Office of Monitoring, Audit and Enforcement Program. “The numbers overall, for the community at large, are quite good.”
During the second quarter, insurers filed 3,812 reports indicating that an employee missed a at least day of work from an on-the-job injury or illness.
Some workers return within a week and a case ends there. Some stay out of work, file for benefits and get approved. Some file and their insurer denies the claim in a “notice of controversy,” or NOC, detailing why.
Carriers have two weeks to tell the state whether they accept or deny a claim and sometimes that’s not enough time to sort out all the facts, said Michael Bourque, spokesman for Maine Employers’ Mutual Insurance Co., the largest workers compensation policy-writer in the state.
Among the questions that have to be answered: Was the injury clearly work related? Has the employer offered a light-duty position, and has the employee accepted? What does the doctor have to say?
“There are disputes that can get murky at times,” he said.
Notice of controversy cases often stop right there, Bourque said. Others use the board’s dispute resolution process.
But too many denials “drives cost and it delays the process,” Minkowsky said. Some claims initially rejected are eventually paid.
Six months’ worth of results isn’t enough to draw any conclusions on unreasonable denials, he said. In the case of Wal-Mart, “there may be an issue of over-reporting.”
With a year of data in place by next summer, the board may set a benchmark, determining how many denials are too many, general counsel John Rohde said.
Not many states track timely compensation filings, and even fewer track notices of controversy, so Maine has little to compare itself to.
In Michigan, which does track disputed claims, the rate is close to 20 percent.
Bourque said his company doesn’t have an approval rate it aims for, but would use its figures in marketing strategy against competitors in the future.
“We would be seriously concerned if we saw a company NOC’ing 90 percent of their claims; we’d find that irresponsible activity,” he said.
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