ISO Reports and Workers Compensation Claims in Virginia

Workers compensation claims can be complex, especially when insurance companies use ISO reports to dispute or deny your claim. This article provides an in-depth look at ISO reports and how they can impact your workers comp claim in Virginia. If you need legal advice for your claim, please contact us at Slominski Law. Attorney Jaleh Slominski has over 30 years of experience helping injured workers get the benefits they deserve.

What is an ISO Report?

Insurance Services Office, Inc. (ISO) provides data and analytics to property and casualty insurance companies. Part of their services includes generating reports that analyze the details of an injury, estimate expected costs and recovery times, and make claims predictions. These proprietary reports allow insurers to assess the viability of a workers comp claim.

Insurers often use ISO reports to dispute the compensability of an injury, the appropriate disability rating, the need for certain treatments or medications, and the length of disability. The recommendations made in ISO reports can negatively impact an injured worker if the insurer denies or disputes the claim based on the ISO findings.

Why Insurers Rely on ISO Reports

Insurers rely heavily on ISO reports because these reports draw from a large database of past workers compensation claims data to make predictions and recommendations. According to ISO, this data encompasses over 1 billion industry-wide claims.

Using all this information and generated report, insurers may consistently manage claims and better predict future costs. Additionally, ISO touts that their reports lead to faster claims resolution. But for injured workers, a quick resolution is often code for a denied or undervalued claim.

Problems With ISO Reports 

While ISO reports provide useful data, there are also downsides to insurers relying too heavily on these automated assessments:

They lack case specifics.

The algorithms used in ISO reports rely on high-level injury characteristics to make comparisons to historical cases. But each worker’s comp claim has unique aspects that require deeper investigation.

The focus is cost prediction, not appropriate care.

ISO reports use past claims costs to estimate what an insurer should expect to pay. But basing claims decisions on what’s financially best for the insurer can deprive injured workers of the care and compensation they deserve under the law.

The methodology is proprietary and undisclosed.

Insurers treat ISO reports as impartial proof to dispute claims, but injured workers have no visibility into the methodology or data sets used to create the reports. This lack of transparency makes it impossible to verify the accuracy and fairness of the reports.

Real-world experts may disagree with the recommendations.

Doctors and workers compensation lawyers can attest to seeing ISO reports with cost estimates, disability ratings, and treatment recommendations that contradict their expertise. But insurers often value the reports over real-world guidance from practitioners familiar with the specifics of a case.

Examples of How ISO Reports May Negatively Impact Work Compensation Claims

To understand the implications of ISO reports on Virginia workers’ comp claims, consider these scenarios of claim disputes rooted in ISO findings:

Denying Surgery Based on ISO Recovery Timelines

Tom hurt his back lifting heavy materials at work. His doctor recommended spinal fusion surgery, but the insurer refused based on the ISO report’s expected recovery timeline. Four appeals later, an independent medical examiner agreed surgery was needed. But the lengthy dispute caused undue pain and disability for Tom.

Disputing the Compensability of Mental Health Conditions

Michelle developed severe anxiety and depression after a robbery at the convenience store where she worked. But her workers comp claim for medical treatment was denied based on the ISO report listing her conditions as pre-existing rather than caused by the work-related trauma.

Challenging the Extent of Permanent Disability

Jack lost function in his dominant hand because of a machine malfunction accident. But the insurer disputed his permanent partial disability rating, saying the ISO report predicted he should regain more use of his injured hand than Jack’s doctor determined to be realistic.

Denying Coverage for Opioid Pain Medications

Debbie has chronic back pain from a workplace slip-and-fall injury that may never fully resolve. But the insurer now refuses to cover her ongoing prescription opioid treatment based on an ISO report guideline advising against long-term opioid use.

We’ve seen situations like these over and over in our three decades of practice at Slominski Law. Insurers use such reports and other justifications to deny care or dispute disability. But the unique factors of each case warrant a more holistic, patient-centered analysis. This is what we advocate for in every Virginia work injury claim we handle.

Strategies for Overcoming ISO Report Disputes

The key to overcoming an ISO report dispute is presenting specific evidence that contradicts the insurer’s position. Strategies include:

Getting an Independent Medical Exam

An evaluation by an Independent Medical Examiner (IME) provides objective proof to counter ISO recommendations. Favorable IME results carry significant weight and often override ISO findings.

Gathering Supporting Medical Records and Letters

Supply documentation of the injury’s impact from the treating doctor, therapists, and other practitioners involved in the case. Their real-world experience with the patient undercuts disputed ISO conclusions.

Leveraging Legal Expertise

An experienced attorney knows how to present facts to undermine questionable ISO stances. Legal representation also puts pressure on the insurer and underscores that the injured worker is serious about pursuing rightful benefits.

Taking the Case to Court

If other appeals fail, filing a lawsuit may be warranted to compel the insurer to provide coverage. The courtroom setting shifts influence away from the insurer’s flawed ISO assumptions back to the merits and medical realities of your situation.

Leaning on 30+ Years of Workers Comp Excellence

Practicing since 1991, Attorney Jaleh Slominski guides injured workers through the appeal process to overcome unjust ISO report denials. With over three decades of experience practicing workers compensation law, she has the legal knowledge to effectively dispute ISO recommendations, demanding insurers provide fair compensation.

Ms. Slominski also has strong relationships with respected doctors and medical experts whose opinions help counter ISO conclusions. She is fully prepared to take cases to court if out-of-court appeals do not resolve unfair claim denials rooted in questionable ISO reports.

The Bottom Line: Do Not Let ISO Reports Deny You Deserved Benefits

Injured workers have legal rights to medical care and disability benefits. But insurers often use ISO reports to stand in the way of workers comp providing this supportive compensation. Too frequently, adjusters treat ISO recommendations as infallible and use them to dispute doctors’ perspectives, ignore case specifics, and prioritize cost reduction over patient wellbeing.

If your Virginia workers comp claim is denied or curtailed based on an ISO report, it is essential to consult a lawyer experienced in overturning these disputes. With Slominski Law fighting on your behalf, you can be confident that your unique case will get proper consideration, rather than dismissed based on an insurance industry algorithm.

To discuss your situation in more detail and learn how Attorney Jaleh Slominski can help protect your right to fair workers comp benefits, schedule your free consultation. Call (434) 384-9400 (Lynchburg office) or (540) 554-3762 (Roanoke office) today.