Enlyte’s 2026 trends report contains a number that should bother anyone reserving workers’ compensation claims. Days from injury to first treatment rose from 9.2 in 2022 to 16.1 in 2025.
Sixteen days. On a soft tissue injury that is the difference between early conservative care and a claimant who has been guarding an injury for over two weeks before anyone examines it.
What else moved
The same report puts allowed medical cost per claimant up 9.5 percent between 2022 and 2025, reaching $4,398. Units of service per claimant rose 12.3 percent to 112.5, which says the increase came from volume of care rather than from price.
Urgent care utilization went from 16.7 percent to 20.5 percent. Injured workers are being seen somewhere other than where the treatment plan gets set.
Two findings carry more weight than the cost trend. Lost-time claims involving behavioral health treatment run roughly four times the medical cost and twice the duration of claims without it. And 67.3 percent of case management cases involved confounding factors, meaning obesity, surgical intervention, depression, or attorney representation.
Two-thirds. The complicated claim is the normal claim.
The two shapes of a large claim
NCCI’s research on claims exceeding $1 million separates them into two populations that behave differently.
Fast-emerging claims cross $1 million within two years. They come from falls from elevation, motor vehicle accidents, traumatic brain injury, burns, severe spinal cord injury, and traumatic fractures. About half end in fatality or permanent total disability. They average more than $3.0 million, and the service mix skews toward home health care.
Slow-emerging claims cross $1 million after two or more years. They come from strain and lifting injuries to the lower back, motor vehicle accidents, and machine or equipment injuries. Around a quarter end in fatality or permanent total. They average $1.6 million, and the service mix skews toward prescription drugs and durable equipment.
Both populations average roughly $700,000 in indemnity. The entire difference in total cost is medical.
Fast-emerging claims identify themselves. A spinal cord injury is severe on day one and every adjuster on the file knows it.
Slow-emerging claims are the problem. They open as a lumbar strain and stay unremarkable for months.
What severity looks like early
The NCCI split points at something practical. If slow-emerging million-dollar claims start as lower back strains, and most lower back strains resolve, the question is what distinguishes the ones that do not.
The confounding factors data gives part of the answer. Obesity, prior surgery, depression, and attorney involvement each independently extend duration, and they cluster. A claimant with two of them behaves differently from a claimant with none, and the difference shows up in the medical history rather than in the first report of injury.
The behavioral health finding sharpens it. Four times the medical cost and twice the duration is not a marginal effect. Where a claimant has a documented history of depression, anxiety, or substance use disorder before the injury, the trajectory of a routine musculoskeletal claim changes.
That history sits in the prior medical records. It is not in the claim file, it is not on the first report, and the adjuster handling 150 open files has no way to find it without reading.
Severity is rising for a reason nobody wants to talk about
Safety National made a point about catastrophic claims that reframes the trend. Improved on-scene triage and trauma care mean more severely injured workers survive. Survival converts a fatality claim into a lifetime medical claim.
The carrier reported a 30 percent increase in claims with incurred losses over $10 million over a three-year period, with growth also in the $5 million to $10 million band. Attendant care rates have doubled over ten years. A quadriplegic claimant in their twenties may need thirty to forty years of round-the-clock attendant care, and extended ICU stays, durable medical equipment, and attendant services sit outside standard fee schedules where they inflate faster than general medical costs.
Cancer presumption laws for first responders have broadened coverage and extended filing windows, adding another long-tail population.
Meanwhile NCCI’s 2026 State of the Line reported medical severity up 4 percent and indemnity severity up 4 percent, with lost-time claim frequency down 2 percent. Fewer claims, each one costing more.
Where the medical record does work the claim file cannot
Claims systems hold what happened after the injury. They do not hold what the claimant brought to it.
A comprehensive prior medical history answers questions that change reserving and change strategy. Was there a prior injury to the same body part, and how was it resolved? Is there a documented behavioral health history? What comorbidities are present, and are they controlled? Has the claimant had prior surgery on the affected region? What does the imaging show that predates the injury?
On a claim that opens as a lumbar strain in a 52-year-old with a prior L4-L5 discectomy, treated depression, and a BMI over 35, the reserve should not look like a lumbar strain reserve. It frequently does, because nobody has read the prior records and nobody will until the claim has already gone sideways.
The economics favor reading early. NCCI found that large claims represent under 0.5 percent of lost-time claims and up to 15 percent of total indemnity and medical cost. You do not need to review every file. You need to review the ones that carry the markers, and the markers are visible in the medical history within the first ninety days.
The excess carrier’s angle
For an excess writer, this data cuts differently.
Most excess workers’ compensation forms give the carrier no duty to investigate or defend. One specimen states plainly that the carrier “has no duty to investigate, handle, settle or defend any claim”. Another puts the obligation on the insured: “You will investigate and defend any claim, suit or other processing against you.”
What the carrier does hold is notice rights and audit rights. Star’s form requires notice on brain or spinal cord injury, second or third degree burns over 25 percent of the body, amputation, permanent total disability, and hospitalization exceeding one month.
Those triggers catch fast-emerging claims. They do not catch the lumbar strain that will cross $1 million in year four.
An excess carrier that wants earlier visibility into its slow-emerging exposure has one lever, which is reviewing the insured’s file rather than waiting for the notice trigger. That is a second-opinion exercise on a small number of files selected by marker rather than by reported severity.
AmTrust’s excess workers’ compensation submission asks prospective insureds about nurse case management usage and other triage services. Medical management intensity is being treated as a rating input. An insured who can evidence early clinical review on flagged files is answering that question better than one who cannot.
The uncomfortable arithmetic
Sixteen days to first treatment, two-thirds of managed cases carrying confounding factors, and behavioral health quadrupling cost describe a claim population that is harder than the one most reserving assumptions were built on.
The information needed to sort it exists. It sits in medical records that nobody has time to read, on claims that do not look urgent, held by adjusters carrying more files than any human can read closely.
That is a capacity problem with a straightforward answer, and the answer is not asking adjusters to work harder.
CUBEXLE prepares prior medical history reviews and comorbidity summaries for TPAs, self-insured employers, and excess carriers, built around the markers that separate a routine file from a developing one.