AK Claims Adjuster flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Major contributing cause

The work injury must be the most significant cause of the disability or need for treatment, not merely a contributing factor.

Arising out of employment

The injury must have a causal connection to the work activities, such as occurring during a work task or due to a work condition.

In the course of employment

The injury must occur within the time, place, and circumstances of the employment, including reasonable activities incidental to work.

Exclusive remedy

Workers' compensation is the exclusive remedy against the employer for covered injuries, barring civil suits except for intentional torts.

Notice of injury

The employee must notify the employer of a work injury within 30 days; failure may bar the claim absent good cause or employer knowledge.

Claim filing deadline

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

Controversion

The employer's formal denial of benefits, filed within 21 days of receiving the claim, stating the reasons for denial.

First report of injury

The employer must file this report with the Board within 10 days of knowledge of the injury.

Spendable weekly wage

The employee's gross earnings minus taxes and other deductions, averaged over the previous 13 weeks, used to calculate benefit rates.

Temporary total disability

Paid at 80% of spendable weekly wage when the employee is unable to work and has not reached medical stability.

Permanent partial disability

Paid based on impairment rating and wage, calculated as rating (%) times statutory multiplier times spendable weekly wage.

Medical stability

The point when the condition has reached a plateau and further treatment is not expected to improve the condition.

Impairment rating

A percentage of whole person impairment determined by a physician using the AMA Guides, used to calculate PPD benefits.

Reemployment benefits

Vocational rehabilitation benefits offered by the employer to help the employee return to work after a work injury.

Second independent medical evaluation

An evaluation by a neutral physician when there is a dispute over medical issues, such as impairment rating or causation.

Board hearing

A formal proceeding before the Alaska Workers' Compensation Board to resolve disputed claims, with a decision issued within 30 days.

Appeal to Superior Court

A party may appeal the Board's decision to the Alaska Superior Court within 30 days of the decision.

Settlement agreement

A compromise of benefits that must be approved by the Board to be effective.

Fraud indicators

Red flags such as inconsistent medical reports, surveillance evidence, or claimant activity inconsistent with claimed disability.

Unfair claim settlement practices

Prohibited acts like unreasonable delay, failure to investigate, or misrepresentation of facts, subject to penalties.

Confidentiality

The adjuster must protect claimant information and release it only as authorized by law.

Penalty for unpaid compensation

The Board may award a 25% penalty on unpaid compensation if the employer controverts without sufficient evidence.

Medical benefits duration

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

Death benefits

Include burial expenses up to a statutory cap and weekly benefits to dependents.

Travel for medical care

Reasonable travel expenses to obtain medical treatment are compensable medical benefits.

Intoxication defense

Coverage may be denied if the injury resulted from intoxication, but the employer must prove the intoxication was the cause.

Willful misconduct defense

Coverage may be denied if the injury resulted from the employee's willful misconduct, such as violating safety rules.

Mental stress claim

Compensable only if work-related stress is the predominate cause and the claim is not based on disciplinary action.

Recreational activity

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

Traveling employee

Injuries during travel are compensable if the travel is part of the employment or the employee is on a special mission.

Third-party liability

The adjuster must identify potential third-party liability and preserve subrogation rights under AS 23.30.015.

Documentation

The adjuster must document all contacts, decisions, and rationale in the claim file to support the defense.