AK Claims Adjuster cheat sheet

The Alaska Workers' Compensation Act is codified at AS 23.30; the Alaska Workers' Compensation Board regulations are at 8 AAC 45.

Coverage applies to employers with one or more employees; agricultural, domestic, and certain part-time employees have limited or elective coverage under AS 23.30.230.

Injury must arise out of and in the course of employment (AS 23.30.395); the 'arising out of' test requires a causal connection to work, and 'in the course of' requires the injury occur within the time, place, and circumstances of employment.

The exclusive remedy provision (AS 23.30.055) bars civil suits against the employer for covered injuries, except for intentional torts.

Notice of injury must be given to the employer within 30 days (AS 23.30.100); failure to give timely notice may bar the claim absent good cause or employer knowledge.

A claim for benefits must be filed within two years of the injury or last payment of compensation (AS 23.30.105).

The Board may award a 25% penalty on unpaid compensation if the employer controverts without sufficient evidence (AS 23.30.155(e)).

Medical benefits are payable for as long as the injury requires, with no statutory cap (AS 23.30.095).

The Alaska Workers' Compensation Board consists of three members: one labor, one industry, and one public member (AS 23.30.005).

First report of injury must be filed with the Board within 10 days of employer knowledge (AS 23.30.020; 8 AAC 45.030).

The employer must file a controversion (Form 07) within 21 days of receiving the claim if benefits are denied (AS 23.30.155(d)).

The adjuster must conduct a prompt, thorough investigation: interview the employee, witnesses, and supervisor; obtain medical records and wage statements; and inspect the worksite when feasible.

A compensability decision must be based on the 'substantial evidence' standard, considering all available medical and factual information.

The adjuster must document all contacts, decisions, and rationale in the claim file; failure to document can undermine the defense.

The adjuster must identify potential third-party liability (e.g., motor vehicle accidents, defective equipment) and preserve subrogation rights under AS 23.30.015.

The adjuster must ensure timely payment of benefits: first payment of temporary total disability (TTD) is due within 14 days after the employer has knowledge of the injury (AS 23.30.155).

The adjuster must monitor the claim for fraud indicators, such as inconsistent medical reports, surveillance evidence, or claimant activity inconsistent with claimed disability.

A compensable injury must be the major contributing cause of the disability or need for treatment (AS 23.30.010).

The 'major contributing cause' standard requires the work injury to be the most significant cause, not merely a contributing factor.

Pre-existing conditions do not bar compensation if the work injury is the major contributing cause of the disability or need for treatment.

Mental stress claims are compensable only if the work-related stress is the predominate cause and the claim is not based on disciplinary action (AS 23.30.395).

Injuries sustained during recreational activities are generally not compensable unless the activity is required by the employer.

Injuries during travel are compensable if the travel is part of the employment (e.g., traveling salesperson) or if the employee is on a special mission for the employer.

Coverage may be denied if the injury resulted from intoxication or willful misconduct (AS 23.30.235).

The employer may require an employee to submit to a medical examination by a physician of the employer's choice (AS 23.30.095).

Temporary total disability (TTD) is paid at 80% of the employee's spendable weekly wage, subject to a maximum rate (AS 23.30.185, 23.30.220).

TTD is payable while the employee is unable to work and has not reached medical stability; once medical stability is reached, TTD ends.

Temporary partial disability (TPD) is paid when the employee returns to work at reduced hours or wages due to the injury; the rate is 80% of the difference between the employee's pre-injury spendable wage and post-injury wage.

Permanent total disability (PTD) is paid when the employee is permanently unable to work; the rate is 80% of the spendable weekly wage, subject to a maximum.

Permanent partial disability (PPD) is paid based on the impairment rating and the employee's wage; the formula uses the rating and the statutory multiplier (AS 23.30.190).

Medical benefits include all reasonable and necessary medical treatment, including physician visits, hospitalization, surgery, prescriptions, and travel for medical care (AS 23.30.095).

The employee is entitled to choose the initial treating physician, but the employer may require a change if the physician is not providing appropriate care (AS 23.30.095).

Death benefits include burial expenses (up to a statutory cap) and weekly benefits to dependents (AS 23.30.215).

The adjuster must calculate the spendable weekly wage using the employee's gross earnings, minus taxes and other deductions, averaged over the previous 13 weeks (AS 23.30.220).

Permanent partial impairment (PPI) is determined by a physician using the American Medical Association Guides to the Evaluation of Permanent Impairment, as adopted by the Board (AS 23.30.190).

The impairment rating must be expressed as a percentage of the whole person.

PPD benefits are calculated as: impairment rating (%) × statutory multiplier × spendable weekly wage, subject to a maximum (AS 23.30.190).

The employee must reach medical stability before PPD is paid; medical stability means the condition has reached a plateau and further treatment is not expected to improve the condition.

The employer may offer reemployment benefits (rehabilitation) to assist the employee in returning to work (AS 23.30.041).

If the employer does not offer reemployment benefits within 90 days after the employee reaches medical stability, the employee may be entitled to a presumption of eligibility for reemployment benefits.

The adjuster should coordinate with vocational rehabilitation counselors to facilitate return to work and document all efforts.

The adjuster must ensure that PPD ratings are based on the most recent edition of the AMA Guides as adopted by the Board.

The employee may request a second independent medical evaluation (SIME) if there is a dispute over the impairment rating (AS 23.30.095(k)).

The employer must file a First Report of Injury (Form 07) with the Board within 10 days of knowledge of the injury (8 AAC 45.030).

The employer must file a Controversion (Form 07) within 21 days of receiving the claim if benefits are denied (AS 23.30.155(d)).

The employer must file a Notice of Payment (Form 08) within 10 days of making the first payment of compensation.

The adjuster must maintain accurate records of all payments, medical treatments, and communications in the claim file.

The adjuster must report to the Board any change in the employee's status, such as return to work or change in disability.

All claim documents must be retained for at least six years after the claim is closed (8 AAC 45.030).

The adjuster must ensure that all forms are complete and accurate; incomplete forms may delay benefits and lead to penalties.

The adjuster must provide copies of medical reports to the employee upon request (AS 23.30.107).

The employee may file a Claim for Compensation (Form 07) with the Board to initiate a dispute (8 AAC 45.040).

The Board may schedule a prehearing conference to simplify issues and encourage settlement (8 AAC 45.060).

A hearing is held before the Board, which may be conducted by a single Board member or a panel (AS 23.30.110).

The Board must issue a decision within 30 days after the hearing (AS 23.30.110).

A party may appeal the Board's decision to the Alaska Superior Court within 30 days (AS 23.30.125).

The Board may award attorney fees to the employee if the employer's position was frivolous or unreasonable (AS 23.30.008).

The adjuster must ensure that all evidence, including medical records and witness statements, is available for the hearing.

Settlement agreements must be approved by the Board if they compromise benefits (8 AAC 45.160).

The adjuster should participate in the hearing process by providing necessary documentation and testimony.

Adjusters must conduct themselves with honesty, integrity, and professionalism, and must not misrepresent facts or policy provisions.

Adjusters must not engage in unfair claim settlement practices, such as unreasonable delay or failure to investigate (AS 21.36.125).

Adjusters must not pay or accept any inducement to settle a claim improperly.

Adjusters must report suspected fraud to the Alaska Division of Insurance and cooperate with investigations (AS 21.36.360).

Workers' compensation fraud includes making false statements, concealing information, or staging accidents to obtain benefits.

The adjuster must maintain confidentiality of claimant information and release it only as authorized by law.

The adjuster must avoid conflicts of interest and must not have a financial interest in the outcome of a claim.

The adjuster must ensure that all communications are accurate and not misleading.

The adjuster must comply with continuing education requirements to maintain licensure.