Adjuster X

A Tale of Turbulence

By: | November 1, 2013 • 3 min read
This column is based on the experiences of a group of long-time claims adjusters. The situations they describe are real, but the names and key details are kept confidential. Michelle Kerr is the editor of this column and can be reached at [email protected]

The loss report for Gloria, a 47-year-old flight attendant, noted a left-hand strain from securing a beverage cart during air turbulence, and also carpal tunnel syndrome. Gloria had received initial treatment at a 24-hour clinic, but the clinic wouldn’t provide details without a signed HIPAA release.

The flight log confirmed episodic turbulence. A co-worker saw Gloria’s cart roll backwards, but never saw it touch her.

Advertisement




Within two days, the employer received an attorney letter of representation, and a request for payment of temporary total disability. We acknowledged the representation and asked Gloria to sign a HIPAA release. I assigned a nurse case manager but she didn’t get responses from the attorney.

Our claim representative learned Gloria had three group claims involving lost time related to stress due to a divorce and a child’s car accident. The ISO query of prior accidents ran eight pages covering nine years, including three falls in retail stores with multiple body parts injured; a fall on ice in a parking lot with neck, arm and leg injuries; and four back, hand and knee claims when she worked for other airlines. Prior to this incident, she had three workers’ compensation claims with her current employer involving back and hands. Follow-up requests for more detailed information were sent to the other carriers noted on the reports.

By now, the first lost-time payment was due. But all we knew was that a cart had rolled and may or may not have struck Gloria. The attorney was unresponsive. I decided not to issue a check, citing lack of substantiating medical information. Letters were sent to Gloria, her attorney and the employer. It was another month until we received the HIPAA release and permission for nurse case management.

The case manager’s report described an individual who was focused on being injured and took a lot of pain medication. Gloria had been hospitalized more than two dozen times — half of those involved hand or knee surgery. The case manager felt she had psychosocial impediments to returning to work. She was taking high doses of antidepressants and had a victim mentality. Gloria felt certain she needed carpal tunnel surgery, which she blamed on the airline’s equipment. The case manager suggested medical evaluations on the causal relationship of carpal tunnel and a psychologist referral.

Our attorney recommended that we pay the accrued indemnity benefits for the hand injury to avoid penalties and fines. But he deferred judgment on the carpal tunnel syndrome. We agreed Gloria appeared to have psychological issues.

Advertisement




The reports we received painted a disturbing picture. Hospital records cited 911 calls to Gloria’s home as a result of injuries to her hands while peeling potatoes. On another, she had fallen, admitting use of sleep medications and pain relievers. Surveillance showed her performing manual labor at her house.

All parties agreed that Gloria was setting the stage for a finding of permanent and total disability. Although we could have fought to defeat the claim, we felt that settlement was the best fiscal strategy. By leveraging the medical and psychological reports as well as the surveillance, we were able to settle the case. We took credit for indemnity paid and agreed to three years of future comp. It wasn’t a dream ending, but at least it wasn’t even more of a nightmare.

More from Risk & Insurance

More from Risk & Insurance

2017 Teddy Awards

The Era of Engagement

The very best workers’ compensation programs are the ones where workers aren’t just the subject of the program, they’re a part of it.
By: | November 1, 2017 • 5 min read

Employee engagement, employee advocacy, employee participation — these are common threads running through the programs we honor this year in the 2017 Theodore Roosevelt Workers’ Compensation and Disability Management Awards, sponsored by PMA Companies.

A panel of judges — including workers’ comp executives who actively engage their own employees — selected this year’s winners on the basis of performance, sustainability, innovation and teamwork. The winners hail from different industries and regions, but all make people part of the solution to unique challenges.

Advertisement




Valley Health System is all-too keenly aware of the risk of violence in health care settings, running the gamut from disruptive patients to grieving, overwrought family members to mentally unstable active shooters.

Valley Health employs a proactive and comprehensive plan to respond to violent scenarios, involving its Code Atlas Team — 50 members of the clinical staff and security departments who undergo specialized training. Valley Health drills regularly, including intense annual active shooter drills that involve participation from local law enforcement.

The drills are unnerving for many, but the program is making a difference — the health system cut its workplace violence injuries in half in the course of just one year.

“We’re looking at patient safety and employee safety like never before,” said Barbara Schultz, director of employee health and wellness.

At Rochester Regional Health’s five hospitals and six long-term care facilities, a key loss driver was slips and falls. The system’s mandatory safety shoe program saw only moderate take-up, but the reason wasn’t clear.

Rather than force managers to write up non-compliant employees, senior manager of workers’ compensation and employee safety Monica Manske got proactive, using a survey as well as one-on-one communication to suss out the obstacles. After making changes based on the feedback, shoe compliance shot up from 35 percent to 85 percent, contributing to a 42 percent reduction in lost-time claims and a 46 percent reduction in injuries.

For the shoe program, as well as every RRH safety initiative, Manske’s team takes the same approach: engaging employees to teach and encourage safe behaviors rather than punishing them for lapses.

For some of this year’s Teddy winners, success was born of the company’s willingness to make dramatic program changes.

Advertisement




Delta Air Lines made two ambitious program changes since 2013. First it adopted an employee advocacy model for its disability and leave of absence programs. After tasting success, the company transitioned all lines including workers’ compensation to an integrated absence management program bundled under a single TPA.

While skeptics assume “employee advocacy” means more claims and higher costs, Delta answers with a reality that’s quite the opposite. A year after the transition, Delta reduced open claims from 3,479 to 1,367, with its total incurred amount decreased by $50.1 million — head and shoulders above its projected goals.

For the Massachusetts Port Authority, change meant ending the era of having a self-administered program and partnering with a TPA. It also meant switching from a guaranteed cost program to a self-insured program for a significant segment of its workforce.

Massport’s results make a great argument for embracing change: The organization saved $21 million over the past six years. Freeing up resources allowed Massport to increase focus on safety as well as medical management and chopped its medical costs per claim in half — even while allowing employees to choose their own health care providers.

Risk & Insurance® congratulates the 2017 Teddy Award winners and holds them in high esteem for their tireless commitment to a safe workforce that’s fully engaged in its own care. &

_______________________________________________________

More coverage of the 2017 Teddy Award Winners and Honorable Mentions:

Advocacy Takes Off: At Delta Air Lines, putting employees first is the right thing to do, for employees and employer alike.

 

Proactive Approach to Employee SafetyThe Valley Health System shifted its philosophy on workers’ compensation, putting employee and patient safety at the forefront.

 

Getting It Right: Better coordination of workers’ compensation risk management spelled success for the Massachusetts Port Authority.

 

Carrots: Not SticksAt Rochester Regional Health, the workers’ comp and safety team champion employee engagement and positive reinforcement.

 

Fit for Duty: Recognizing parallels between athletes and public safety officials, the city of Denver made tailored fitness training part of its safety plan.

 

Triage, Transparency and TeamworkWhen the City of Surprise, Ariz. got proactive about reining in its claims, it also took steps to get employees engaged in making things better for everyone.

A Lesson in Leadership: Shared responsibility, data analysis and a commitment to employees are the hallmarks of Benco Dental’s workers’ comp program.

 

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]