Claims

Workers' compensation has become increasingly vulnerable to claimant fraud. In today's stagnant economy, employers, insurance companies, and claim organizations face significant financial pressures, and the last thing they want is to lose additional funds to those aimed at cheating the system - either through outright fraud or opportunistic maligning.|

When an employee gets hurt at work, or at least claims that they did, it can be a very stressful time for employers. In addition to following the applicable reporting requirements, there are several things employers can do to help develop a stronger defense.

The Medical Treatment Utilization Schedule defines functional restoration as a process by which the individual acquires the skill, knowledge and behavioral change necessary to avoid preventable complications and assumes or re-assume primary responsibility ("locus of control") for his/her own physical and emotional well-being post-injury.

Understanding the basics of Commercial General Liability coverage and the carrier's duty to defend or indemnify will assist greatly in setting up the correct claim file or files, and evaluating the claim from a perspective that will maximize the recovery from the standpoint of the sponsor or tendering party.

In residential construction, wrap-up policies that cover all of the builders' projects under construction are becoming increasingly popular. These are sometimes referred to as "rolling wraps,” since they "roll” from one project to the next. Individual contractors and subcontractors enrolled in the home builders' wrap-up plan for work pursuant to a specific subcontract or project. The difficulty can occur when a rolling wrap is created while projects are ongoing.

In short, mechanics liens claims present every complication of an Owner Controlled Insurance Program. The sponsor/ owner is the insurance company's adversary if there is a covered claim against an insured contractor. The insurance claims may not be procedurally separate from the contract claims, which makes assigning counsel and representation of the contractor more difficult. To successfully resolve such claims, communications and clear objectives between the enrolled contractor and the insurance company are critical, if there is to be a voluntary contribution to the settlement by the insurance company.

Under a typical general liability policy, if a claim presented against an "insured” is partially covered by the policy, the insurance carrier issues a reservation of rights. The reservation of rights letter identifies those claims, causes of action, or damages that are not covered by the policy.|

In the construction contract, there will be contractual language relating to the procurement of insurance and the operation of the Owner Controlled Insurance Program. In the context of property damage claims for damage occurring to the project itself, those contracts may articulate defenses available to the enrolled contractors. Two of the most important would be the waiver of subrogation clause and the identification of builders risk insurance.|