Marie, a dedicated workers' compensation adjuster, faces an endless stream of complex claims.

Tycho Speekenbrink

Understaffed colleagues leave injured workers feeling ignored and undervalued. Efficiency demands overshadow her efforts to provide personalized support, leading to dissatisfaction and burnout. Despite her best efforts, Marie knows the system's flaws and recognizes the urgent need for a more balanced approach. 

The workers' compensation industry is facing challenges as overworked adjusters struggle with complex claims while injured workers feel unheard and undervalued. The industry's focus on efficiency often prioritizes cost reduction over personalized support. This creates a high-pressure work environment for adjusters, leading to dissatisfaction, turnover and understaffing. Ultimately, this compromises the quality of service for injured workers and, in turn, leads to an increase in costs.

John Peters

By automating routine tasks, AI can free adjusters to focus on the human aspects of their work that require empathy, nuanced judgment and creative problem-solving. AI can also provide data-driven insights to support decision-making, equipping adjusters with crucial information to perform their jobs effectively and empathetically. 

AI’s potential to transform the role of an adjuster envisions a future where technology and human expertise are combined. The result is a more efficient, supportive and equitable claims process that benefits adjusters and injured workers alike.

Evolving role of the claims adjuster

Experienced adjusters are increasingly leaving their roles due to burnout and overwhelming workloads. The growing complexity of cases and the burden of administrative duties pushes these seasoned professionals to seek more sustainable career paths.

At the same time, there are significant challenges in attracting qualified new talent, as well, particularly among Generation Z, the latest cohort to enter the workforce. This generation, more than any before, prioritizes careers that offer autonomy, leverage problem-solving abilities and provide a sense of purpose and job satisfaction. Having grown up in a digital world, Gen Z views technology as an integral part of both its personal and professional lives. 

Injured worker perspective

Beyond the workforce, the expectations of those served by the industry are also evolving. In today's digital age. Consumers expect 24/7 access to services and information. Injured workers are no different. They expect immediate attention to their claim details and continuous updates.

Injured workers, like all consumers, value the convenience of digital services, but their unique circumstances heighten the importance of human interaction. Injured workers are vulnerable, dealing with physical pain, emotional stress and financial uncertainty. AI may expedite claims, but it cannot replace the compassion and individualized support that injured workers need to navigate their recovery journey.

When genuine human connection is absent, injured workers are more likely to experience frustration, resentment and a sense of isolation. This emotional toll can lead to dissatisfaction, distrust and hindered recovery, prolonging treatment and escalating costs. In some cases, this may even escalate into seeking legal recourse, complicating the claims process and increasing costs for all parties involved.

Streamlining the claims process

AI's 24/7 availability, combined with its ability to rapidly process vast amounts of data, streamline assessments and consistently apply complex rules across a wide range of scenarios, presents an opportunity to transform the industry. When a first notice of loss (FNOL) is filed, the accompanying documents often require in-depth individual reviews. AI can extract and consolidate crucial information from medical reports, bills and other relevant sources into a clear, concise format. By analyzing this data and cross-referencing it with historical claim patterns, AI can make an immediate judgment on the validity of the claim. 

Furthermore, AI can function as an intelligent assistant, responding to inquiries from injured workers, resolving procedural questions and leveraging a broad range of data sources to provide prompt and accurate answers to common questions about coming appointments, payment timelines and the overall claims process. This includes streamlining tasks such as scheduling appointments with health care providers based on real-time availability. This not only saves adjusters valuable time but also enhances the injured worker’s experience.

Enhancing adjusters' effectiveness

Adjusters use their empathy and emotional intelligence to build rapport with injured workers. Many adjusters excel at navigating complex, nuanced cases that require consideration of multiple, often conflicting factors. This human touch results in a smoother claims resolution. AI, as a collaborative partner, can enhance these strengths by providing adjusters with data-driven insights, enabling them to make more informed decisions and provide even better support to injured workers.

A workers' compensation claim can be an emotional process, and some injured workers are more adept at handling it than others. AI-powered tools analyze the emotional well-being of the injured workers’ communications. These insights can be leveraged for the adjuster to formulate responses accordingly. This capability allows adjusters to provide more personalized and empathetic support.

This ability to personalize information opens up possibilities for adjuster training. Imagine a virtual coach that analyzes your injured worker interactions during a call, offering immediate feedback on communication style, empathy and active listening skills. Similar to how AI-powered language learning tools are already helping individuals refine their conversational abilities, this technology could empower adjusters to continuously improve their communication and interpersonal effectiveness.

By leveraging insights learned from countless interactions, AI can tailor its advice to address specific areas where an adjuster might need improvement. This personalized approach ensures that training is always relevant, helping adjusters refine their skills and ultimately deliver better service to the injured worker.

Responsible AI implementation

The development and integration of AI systems will require significant time and investment, along with careful consideration of ethical, security and data privacy concerns. Resistance to change is a natural part of any technological shift and should be expected with the implementation of AI.

Increased efficiency should not come at the cost of dehumanizing the claims process. If AI is implemented solely to drive productivity, it could inadvertently exacerbate existing issues. The anticipated efficiency gains might lead to an increase in the number of claims assigned to each adjuster, further burdening an already overworked workforce. While AI-powered training tools hold potential, they could also be misused to monitor conversation times and result in a new level of control. This misuse of excessive monitoring could lead to a demoralizing and micromanaged environment.

Balancing efficiency and empathy

Workers' compensation claim adjusters grapple with overwhelming caseloads, complex claims and pressure to prioritize efficiency over personalized care. This challenging environment often leads to high job turnover and makes it difficult to attract and retain qualified talent.

AI presents an opportunity to enhance the claims process, creating a more efficient and empathetic approach to serving injured workers while simultaneously making adjusters' work more rewarding and important. By automating routine tasks and analyzing complex data, AI empowers adjusters to focus on empathy and communication and enhances these unique skills through AI-powered insights and feedback. 

Successful implementation requires a thoughtful approach that balances efficiency with empathy, ensuring that AI complements rather than replaces human expertise. By embracing this technology responsibly, the industry can create a future where both adjusters and injured workers benefit.

Tycho Speekenbrink is an insurance professional with a decade of experience in Europe, Asia and America. John Peters is co-founder and chief science officer of Gain Life. This blog post is reprinted with permission from InsuranceThoughtLeadership.com.