The First 72 Hours of a Lost-Time Claim
Purpose
The first 72 hours largely determine whether a claim becomes:
- A routine recovery
- A prolonged disability claim
- A litigated claim
- A high-cost claim
This playbook provides a structured approach to investigation, communication, medical management, and documentation.
Scenario
- Employee reports a back injury lifting materials.
- Missed work begins immediately.
- No attorney involvement.
- No obvious compensability concerns.
During the first 72 hours:
✅ Determine compensability
✅ Establish rapport
✅ Direct medical care appropriately
✅ Gather facts before memories fade
✅ Identify return-to-work opportunities
✅ Set accurate reserves
✅ Document the file correctly
Every adjuster should answer these questions before day three.
1. What exactly happened?
Avoid:
“Employee hurt back lifting.”
Instead capture:
“Employee lifted a 75-pound box from pallet to shoulder-height shelf and felt immediate pain in lower back.”
2. Who witnessed the event?
Obtain:
- Names
- Titles
- Contact information
Document:
- What they saw
- What they heard
- Timing consistency
3. Was the injury reported promptly?
Questions:
- Date of injury?
- Date reported?
- To whom reported?
Red Flag:
A significant reporting delay.
4. Is the mechanism medically plausible?
Compare:
Injury allegation
vs.
Medical records
Example:
If worker reports:
severe shoulder injury while lifting
but ER records indicate:
condition developed gradually over three weeks
investigation should expand.
5. What work restrictions exist?
Never document:
“Restricted duty.”
Document:
- No lifting over 10 lbs.
- No climbing.
- Alternate sitting and standing.
- No overhead reaching.
Specific restrictions drive return-to-work planning.
6. Is modified duty available?
Contact employer.
Ask:
- Can restrictions be accommodated?
- Temporary assignment available?
- Transitional duty program?
7. Are there recovery obstacles?
Potential obstacles:
- Transportation
- Language barriers
- Prior injuries
- Chronic pain history
- Labor dispute
- Job dissatisfaction
These do not determine compensability.
They affect outcomes.
8. What could make this claim expensive?
Examples:
- Surgery risk
- Attorney involvement
- Comorbidities
- Delayed treatment
- Catastrophic potential
- Poor employer relationship
Injured Worker
Goal
Build trust early.
Opening questions:
- How are you feeling today?
- What concerns do you have?
- What has the doctor told you?
- What can I help you with right now?
Avoid interrogating.
Start with listening.
Employer
Goal
Establish partnership.
Questions:
- What happened?
- Were there witnesses?
- Is modified duty available?
- Any prior issues involving this employee?
- Any surveillance or video?
Medical Provider
Obtain:
- Work status
- Restrictions
- Treatment plan
- Follow-up appointment
- Diagnostic testing plans
Not every red flag means fraud.
Red flags simply mean:
Investigate further.
Common Red Flags
- Injury Monday morning
- No witnesses
- Delayed reporting
- Conflicting histories
- Pending termination
- Significant overtime before injury
- Prior similar claims
Within First 72 Hours
Review:
- Initial report
- Restrictions
- Diagnosis
- Prognosis
- Follow-up schedule
Ask:
What drives recovery?
Examples:
- Physical therapy?
- Specialist referral?
- MRI?
- Surgery consult?
Develop action plan.
Initial Questions
What is currently known?
- Medical only?
- Lost time?
- Surgery possibility?
- Attorney representation?
- Permanent impairment potential?
Common Mistake
Setting reserves based solely on diagnosis.
Example:
Two identical lumbar strains may have very different exposures depending on:
- Occupation
- Wages
- Return-to-work options
- Recovery progress
Every file should have clear next steps.
Day 3 Diary
- Review medical note
- Verify restrictions
- Confirm employer accommodation
Day 7 Diary
- Check treatment attendance
- Evaluate work status
Day 14 Diary
- Recovery progress review
- Reserve review
- Settlement considerations if appropriate
Mistake #1
Focusing on the injury instead of recovery.
Better question:
What is preventing this worker from returning to function?
Mistake #2
Talking only with employers.
Claimants who feel ignored often become represented.
Mistake #3
Ignoring psychosocial factors.
People recover from injuries.
People struggle more with uncertainty.
Mistake #4
Passive claim handling.
Good adjusters move the claim.
Poor adjusters watch the claim.
At 72 hours:
MeasureGoalEmployee ContactCompletedEmployer ContactCompletedMedical Records ObtainedCompletedRestrictions IdentifiedCompletedRTW Discussion HeldCompletedCompensability EvaluatedCompletedReserves SetCompletedDiary Plan CreatedCompleted
The first 72 hours are not primarily about paying benefits.
They are about creating direction.
A well-managed claim begins with a clear understanding of the injury, frequent communication, realistic recovery expectations, and a documented plan for moving the worker toward function and return to work. Every action in the first three days should answer one question:
What is the next step most likely to help this claim recover efficiently and successfully?
