By Gary Jennings, CPCU,
ARM, ALCM, AIC, ARe, SCLA
“If You’re in a Hole,
that the employee fell from atop the sink
while inspecting his hemorrhoids in the
mirror. I cannot think of one lesson that
I learned from this incident, other than
the fact that I can’t believe he reported the
claim as accurately as he did. Also, I can’t
seem to get that picture out of my mind.
Now… to more serious items.
Workers’ compensation claims
Some of the most unusual claims arise
out of work-related incidents, and sometimes an injury can have an unexpected
and beneficial outcome. Many years ago,
an adjuster managed a workers’ compensation claim in which an employee in a
factory that manufactured seat belts rose
up from a bent position and struck his
lower back on the arm of a machine. Unfortunately he rose up very quickly, causing a great deal of pain. He went to the
first aid office, which in that large plant
was staffed by a registered nurse.
He was then sent to one of the physicians on the medical panel, which began
a strange turn of events.
The initial diagnosis was that of a muscle strain. However, he did not respond
to the conservative care as quickly as expected, so he was sent to an orthopedist.
During the course of the examinations
and follow-up, including an MRI and an
independent medical examination (IME),
it was found that the employee had cancer
in his back. Obviously that was very tragic,
but the fact remains that this was found as
the result of treatment for a work-related
injury, and the employee was able to start
cancer treatment quickly.
The adjuster had assigned this claim to
an in-house nurse case manager because
this back injury had not been resolving as
expected. Upon learning of the cancer diagnosis, the adjuster and nurse case manager agreed that they needed to quickly
separate the treatment and disability
for the back injury from the employee’s
treatment and disability for the cancer.
Through the help of the orthopedist, the
oncologist who was brought in to treat
the employee’s cancerous condition, and
the insurer’s medical advisor, they were
able to isolate, as best as possible, the impact of each condition.
We often see unusual occurrences and claims in the claims management world, including claims that take strange turns and twists. Sometimes these twists and turns are
comical, while on other occasions they can be tragic. In some rare
cases, the unfortunate occurrence of a work-related injury can lead to
discoveries that ultimately benefit the employee.
I recently read an article by a financial
expert who was writing about overcoming
debt. For people who found themselves
in debt, he recommended that they stop
using their credit cards or “If you’re in a
hole, quit digging.” That is, quit creating
more debt. While that is very sound advice in the financial world, in the claims
world we often find ourselves in a hole,
and it is almost never wise to stop digging.
About 20 years ago the company received a workers’ compensation claim
from an employee in a manufacturing
plant who fell in the bathroom. He was
in an authorized area and there was no
question about the legitimacy of the
claim, since several employees heard him
fall. They ran to his side quickly, and fortunately the injury was minor. However,
the unusual thing about the injury was