Office of Risk Management Annual Conference GENERAL LIABILITY & AUTO LIABILITY (TRANSPORTATION) CLAIMS Office of Risk Management Annual Conference Sedgwick CMS is a TPA (Third Party Administrator). A Third Party Administrator processes claims for a separate entity. Sedgwick administers claims for the Office of Risk Management where a third party is alleging damages in tort due to negligence of the State of Louisiana. Office of Risk Management Annual Conference Tort = a legal wrong committed upon the person or property independent of contract. Negligence = For negligence to exist, there must be: 1.Existence of a legal duty owed to plaintiff by defendant. 2.Breach of duty. 3.Proximate cause between the breach and plaintiff's injury and damages. Office of Risk Management Annual Conference General Liability claims involve those that are not workers comp, do not involve state owned vehicles, medical malpractice or involve damages attributed to state highways. These claims range from trip and falls, to property damage, to civil rights violations, to wrongful acts, for example. Auto (Transportation) claims involve those where negligence is being alleged out of the ownership, maintenance or use of a state vehicle. Office of Risk Management Annual Conference REPORTING OF AUTO/ GL CLAIMS Office of Risk Management Annual Conference General Liability Losses should be reported to ORM through Claim Capture (https://sedgwickcms.claimcapture.com)https://sedgwickcms.claimcapture.com Office of Risk Management Annual Conference Auto Losses should be reported using the DA-2041 Form (within 24 hrs.) and sent to: cms.com Or Fax *Reporting forms for aircraft accident, wet marine, marine vessel accident and vehicle glass can also be located on this website. Office of Risk Management Annual Conference IMPORTANT THINGS TO REMEMBER WHEN A LOSS OCCURS: The agency is not to assume any obligation to incur any expenses without ORM approval. Employees should never admit fault or make unsolicited comments. All damaged property should be protected against future damage and be made available for inspection by Sedgwick. Office of Risk Management Annual Conference IMPORTANT THINGS TO REMEMBER WHEN A LOSS OCCURS: Scene Photos (cell phone & disposable cameras) depicting scene conditions, positioning of vehicles, skid marks, etc. are extremely helpful. Proof of insurance (found on ORM website) should be kept in glove box at all times. DA-2041 should be submitted within 24 hrs. Please include location code when reporting the loss. Office of Risk Management Annual Conference WHAT HAPPENS ONCE THE CLAIM IS REPORTED? 1.Claim is processed by Sedgwick intake center. 2.Claim arrives in a Mail Box of Sedgwick Supervisor. 3.Claim is assigned to examiner based on complexity of the claim. Office of Risk Management Annual Conference THE ADJUSTING PROCESS 1.Investigation 2.Evaluation 3.Negotiation 4.Settlement/Denial Office of Risk Management Annual Conference INVESTIGATION Claims Examiner investigates to confirm if coverage exists. Claims Examiner contacts agency and claimant within 24 hrs. of receipt to confirm facts. 3 attempts should be made within 5 business days. Gathering of all pertinent evidence, to include witness statements, scene investigation/photos, police reports and accident reconstructions. Office of Risk Management Annual Conference EVALUATION All pertinent evidence is analyzed. Do we have liability? Can the liability be apportioned between parties? Louisiana is a pure comparative state, so any liability on the claimant will reduce their recovery from 100% by the degree to which the plaintiffs own negligence contributed to the cause of the injury/damages. Office of Risk Management Annual Conference EVALUATION Damages claimed may be: 1.Special damages = Quantifiable monetary losses such as property damage, medical bills, lost wages, etc. 2.General damages = Non-monetary damages or Pain and Suffering. Office of Risk Management Annual Conference NEGOTIATION Claims can be filed through an attorney (represented) or Pro se (non-represented). Claims Examiner negotiates directly with the above to settle the claim. When lawsuit is filed, the Claims Examiner will work directly with defense counsel in negotiations. Office of Risk Management Annual Conference Settlement/Denial The Claims Examiner can settle claims for less than $25, as long as they are not in litigation or involve DPS or DOC. The Claims Examiner must obtain approval from ORM for settlement of all litigated claims, DPS, DOC and claims with value in excess of $25, All settlements require a release for full/final settlement of all claims, to include a dismissal of any legal action present. A denial of a claim requires ORM approval. Office of Risk Management Annual Conference FUTURE MEDICAL CARE FUND In personal injury suits wherein the court awards medical care and benefits subsequent to judgment, this is paid according to R.S. 39: Medical benefits are paid directly to providers as incurred up to a certain amount and time limit as specified in the settlement or judgment. Office of Risk Management Annual Conference HOW CAN YOU HELP? Take photos of the accident scene/location, to include: 1.Positioning of Vehicles 2.Damage to all property 3.Landmarks 4.Skid Marks/Debris 5.Use an item as a scale indicator (Ex. Coke can next to pothole in pavement). Office of Risk Management Annual Conference HOW CAN YOU HELP? Tell us of conditions that may have contributed to loss: 1.Lighting / Weather 2.Holes or irregular surfaces 3.Cell phone usage (Auto and GL claims) 4.Footwear on claimant (slip and falls) 5.Were warning signs or wet floor signs present? Obtain all pertinent witness information. Report the claim promptly! Office of Risk Management Annual Conference All legal documents, demands and lawsuits against any state agency/employee should be sent immediately to ORM. ATTENTION: Ann Wax and/or Cynthia Troxclair Office of Risk Management Annual Conference Sedgwick Contacts John Olson (225) GL Contacts Travis Alexander (225) Terrie Raffety (225) Transportation Brittany Dyson (225) Main Office: (225) Fax: Office of Risk Management Annual Conference QUESTIONS?