Claims Adjuster Test Workers Compensation Claims 2 — Questions and Answers
Question 1: What is 'permanent partial disability' (PPD) in workers' compensation?
- A lasting impairment that limits but does not completely eliminate the worker's ability to earn wages (Correct answer)
- A condition requiring the worker to be placed in a permanent light-duty position
- A temporary reduction in work capacity that persists for more than one year
- Full disability that results from a specific partial body injury such as a hand or foot
Correct answer: A lasting impairment that limits but does not completely eliminate the worker's ability to earn wages
PPD benefits compensate workers who sustain permanent impairment from a work injury but retain some earning capacity, reflecting the partial and permanent nature of the disability.
Question 2: A claims adjuster receives a workers' compensation claim for a repetitive stress injury. The FIRST step should be to:
- Investigate the claim to determine compensability by gathering medical records and employment history (Correct answer)
- Deny the claim because repetitive injuries are excluded from workers' compensation
- Immediately accept the claim and begin paying benefits
- Refer the claim directly to litigation without further investigation
Correct answer: Investigate the claim to determine compensability by gathering medical records and employment history
The adjuster's first step is always to investigate the claim to determine whether it is compensable, including reviewing medical evidence and the worker's job duties to establish the work-related cause.
Question 3: What is the purpose of an Independent Medical Examination (IME) in workers' compensation?
- To obtain an objective medical opinion from a neutral physician about the extent of the injury and treatment needs (Correct answer)
- To replace the treating physician with a company-appointed doctor permanently
- To determine the maximum amount the insurer is required to pay for medical treatment
- To allow the injured worker to choose their own specialist outside the network
Correct answer: To obtain an objective medical opinion from a neutral physician about the extent of the injury and treatment needs
An IME provides an unbiased medical opinion from a physician not involved in treating the worker, helping adjusters resolve disputes about diagnosis, causation, impairment rating, or treatment necessity.
Question 4: Subrogation in workers' compensation allows the insurer to:
- Recover benefits paid to the injured worker from a negligent third party who caused the injury (Correct answer)
- Subrogate the employer's duty to provide a safe workplace to a third-party safety contractor
- Transfer the claim to a different insurance carrier after the policy period ends
- Recover overpaid benefits directly from the injured employee's wages
Correct answer: Recover benefits paid to the injured worker from a negligent third party who caused the injury
Subrogation gives the workers' comp insurer the right to sue a negligent third party (e.g., a defective equipment manufacturer) to recoup benefits it paid to the injured worker.
Question 5: The 'going and coming' rule in workers' compensation generally states that:
- Injuries sustained while commuting to and from work are not compensable (Correct answer)
- Workers are covered whenever they are traveling in a company vehicle
- All injuries that occur outside the workplace are automatically excluded
- Travel injuries are compensable only if they occur within one mile of the workplace
Correct answer: Injuries sustained while commuting to and from work are not compensable
Under the going and coming rule, the normal commute to and from work falls outside the course of employment, making injuries during that commute non-compensable, with exceptions for travel-related job duties.
Question 6: What is the 'second injury fund' (also called the subsequent injury fund) in workers' compensation?
- A fund that covers the portion of disability attributable to a prior injury when a worker suffers a second work injury, reducing employer liability (Correct answer)
- A reserve set aside for employees who file more than one workers' comp claim in a year
- A secondary insurance policy that pays benefits after the primary coverage is exhausted
- A state-run fund that reimburses employers for all workers' comp premiums after a second claim
Correct answer: A fund that covers the portion of disability attributable to a prior injury when a worker suffers a second work injury, reducing employer liability
The second injury fund encourages employers to hire workers with pre-existing conditions by reimbursing insurers for the excess disability caused by combining a new work injury with a prior impairment.
Question 7: In workers' compensation, 'modified duty' or 'light duty' refers to:
- Temporary job assignments that accommodate the injured worker's medical restrictions while they recover (Correct answer)
- A reduction in the worker's permanent job responsibilities after reaching MMI
- Part-time work offered to all employees during a slow production period
- Duties assigned only to workers who have filed a disputed workers' comp claim
Correct answer: Temporary job assignments that accommodate the injured worker's medical restrictions while they recover
Modified duty assignments allow an injured employee to return to work in a capacity consistent with their medical restrictions, reducing TTD costs and supporting the worker's recovery.
Claims Adjuster Test Workers Compensation Claims 2
What is 'permanent partial disability' (PPD) in workers' compensation?