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Risk Scenarios Live!

Brains Not Brawn

The co-morbidities of age and weight compound a case involving a stubborn and injured construction foreman.
By: | March 19, 2015 • 11 min read
Topics: Risk Scenarios
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

The Injury

The scenario begins with the brief video below:

 

A Grey Area

For five weeks, Mike lives in a grey area populated by denial and tentative healthcare delivery.  Mike reports his injury to his employer and is referred to an occupational medicine specialist. The specialist prescribes Vicodin, a pain killer and Naproxen, an anti-inflammatory.

Mike also discusses light duty alternatives with his employer. Mike tries light duty, taking a stab at acting as a carpenter’s assistant, essentially, cleaning up and doing menial work like sweeping up sawdust and chucking small pieces of wood into the dumpster.

Mike is plagued by pain, and acting against the advice of the occupational medicine specialist, he starts taking two to three Vicodin a day on the job to manage. Buffered by the Vicodin, Mike ignores the verbal agreement he has with his employer and begins to use his shoulder harder.

Partner

Partner

At one point, frustrated with the inaccurate work of an underling, Mike picks up a circular saw and starts making cuts to beams and other hefty pieces of wood.

After six weeks, Mike’s pain hasn’t gotten any better and under pressure from Mike’s employer, Mike’s occupational medicine specialist refers him to an orthopedic specialist.

At the orthopedic surgeon’s office, Mike is sitting on the examination table with the doctor standing before him.

The doctor, a much smaller man than Mike, places his right hand on Mike’s left wrist.

“Okay, try to lift your arm,” the doctor says.

Mike tries to lift his arm with the doctor pushing down against him but is struggling.

“You’re very weak in the shoulder,” the doctor says. “I’m afraid you have a substantial rotator cuff tear but we’ll order an MRI just to be sure,” the doctor says.

“What if it’s torn, what then?” Mike says.

“You’re looking at surgery with a minimum of six months off of work,” the doctor says.

Scenario_BrainsNotBrawn“Six months? Why?” says Mike.

“Rehabilitation from rotator cuff surgery isn’t easy. You could have some setbacks. I’m giving you a conservative estimate,” the orthopedic surgeon says.

“Why operate at all?” says Mike.

“You can’t walk around with a rotator cuff tear in your line of work for any period of time,” the doctor says.

“It’s way too risky for a man your age.”

“I’m only 54, Doc,” Mike says gamely.

“At your age, honestly, you’re going to have to be very diligent in rehab to bring this thing back all the way,” the doctor says, tapping Mike lightly on his injured left shoulder.

The MRI confirms what the doctor felt to be true. Mike has a full thickness tear of his rotator cuff.

“You see that?” the doctor says to Mike as they look at the MRI image together.

“Looks like it’s torn all the way through,” Mike says.

“Yes it is,” the surgeon says. “We need to set a date to operate. And as I said during our last visit, you’re going to have to be diligent in rehab to bring this shoulder back successfully.

A New Reality

As a former high school wrestler and carpenter, Mike is accustomed to injury and injury recovery. It seemed like he recovered from a torn meniscus in his right knee during his wrestling days in a matter of weeks.

Scenario_BrainsNotBrawn

In his twenties, he broke a finger in his right hand in a bar fight in Muscatine, Iowa.

In his thirties, he broke the fifth metatarsal bone in his left foot when he rolled his ankle over a log while dove hunting near Lake Okochobee.

Each time he came back fine. Over the years, Mike developed a quiet confidence that his strong body will never fail him.

But one look at Mike as he sits on his living room couch with his left arm in a sling says that this time might be very different. He’s four weeks post surgery and he’s already gained 20 pounds. Post surgery, his doctor gave him a generous prescription of Oxycontin, 80 pills. Mike still has 50 of those pills, a fact he is keeping from his wife and his doctor.

“Really honey?” his wife says as she stands in the living room doorway watching Mike open another beer as he watches a Florida State football game.

There are three finished beers on the coffee table in front of Mike.  “What?” Mike says as he takes a sip of beer.

“You know what,” his wife says. “You’ve been drinking a lot more beer since you’ve been off work.”

“Not really,” Mike says.

His wife walks closer to Mike and peers into a pizza box.

“You ate that entire pizza?”

“Thin crust,” Mike says by way of a joke.

His wife pauses, not enjoying the joke.

“Are you still taking painkillers? Because you know you shouldn’t be drinking and taking that prescription.”

“Nah, I dumped ‘em in the garbage. I don’t need ‘em anymore.” Mike says.

“Hummmph,” his wife says, not pleased with the whole picture and seeming to doubt Mike’s word.

“What about your physical therapy exercises that you’re supposed to be doing at home?”

“I’m doin’ ‘em,” Mike says.

“When?” his wife asks him.

Mike glares at his wife and she reacts.

“I know what you’re thinking,” she says, crossing her arms.

Scenario_BrainsNotBrawn“You think I’m being a nag. Well I’ve got news for you Mike Manning. Just because I care enough to ask after your health doesn’t make me a nag!”

As soon as she leaves the room, Mike fishes in his pocket and brings out a vial of pills.

With practiced dexterity, Mike uses his slinged left hand to hold the pill bottle while he wrests the top off with his right. Mike pops a pill in his mouth and washes it down with a slug of beer.

Mike had initially taken the painkillers according to the instructions on the bottle. But two months into his recovery, he’s now ingesting twice that amount on a daily basis.

***

Back at his doctor’s office, six weeks post-op, Mike’s shirt is off while the doctor checks his range of motion and his strength.

“Okay, stand up and raise your arm as high as you can,” the doctor says.

Mike gamely raises his arm, but he can’t raise his hand above chest height.

“Keep working hard in therapy,” the doctor says. “How’s your pain?”

Mike gives a pain rating of eight over ten. Excess pain behavior.

“Eh, it still hurts, especially when I’m trying to sleep,” he says.

“Okay, we started you on Oxycontin but I’m going to see if you can get by on Vicodin,” the doctor says.

“Sounds good,” Mike says, avoiding eye contact with the doctor.  Mike still has a renewal on his Oxycontin and he’s happily envisioning doubling up with Oxycontin and Vicodin even before the doctor has put pen to paper to write him a new prescription.

Mike flexes his knee.

“My right knee has started to hurt too,” Mike says. “Don’t know what’s up with that.”

The doctor looks at Mike as Mike flexes the knee.

“It looks like you’ve picked up a considerable amount of weight since you’ve been off Mike. That could be affecting your knee.”

“Yeah, probably so,” Mike said, patting his gut affectionately.

“How’s rehab going?” the doctor says. “You doing the home exercises they’re giving you?”

“Eh…sure,” Mike says.

From the doctor’s expression, he’s not too convinced.

Six months post-injury, Margorie Kessel, a claims supervisor for Mike’s employer’s workers’ compensation carrier, has a look at Mike’s file and does not like what she sees.

“His opioid use is like a runaway train,” Margorie says to herself.

“I’m going to put a nurse on this case.”

Off the Rails

Nine months post-injury, Mike is at physical therapy, lying on his back while a therapist works on his shoulder.

Scenario_BrainsNotBrawn

The physical therapist is holding Mike’s left arm and trying to gain more range of motion by steadily pushing Mike’s shoulder past where it wants to go.

The therapist is straining, and from the expression on his face, even nine months past injury, Mike is experiencing serious pain in the shoulder.

“Wow,” the therapist says.

“You’re as tight now as you were three months ago.”

“I know,” Mike says without much conviction.

The therapist sheds her sweatshirt.

“You’re giving me a workout,” she says. She picks up Mike’s arm again and resumes work.

Just then, another patient shouts out to Mary.

“Hey Mary, can you come over here? I’m not sure what to do on this exercise ball,” the other patient says.

“Sure, just a sec, Mary says.

“Here Mike,” so some work with this hand weight and I’ll be right back.”

The therapist leaves Mike and he continues on with the hand weight.

The therapist comes back.

“Sorry about that. Where were we?” But instead of picking up Mike’s left arm she picks up his right arm.

“It’s the left arm,” Mike says impatiently.

“Oh, right, sorry about that,” the therapist says.

“Okay, let’s see here,” she says, picking up Mike’s left arm.

She strains again, trying to get some motion out of the stiff joint.

She pauses, tuckered out.

“Are you sure you’re doing those home exercises I’ve been giving you?” she says.  How many times is he doing it? How many times are you doing it?  He can’t remember.

“You’re just not making the progress I’d hoped you would at this point.”

“I’m doin’ ‘em,” Mike says, again, somewhat unconvincingly.

Just then, another patient calls out for help from the overworked therapist.

“Hey Mary, am I doing this leg extension correctly?”

“Um, let me see,” Mary says, as Mike rolls his eyes impatiently.

“Hold on a sec, sorry,” Mary says as she puts Mike’s arm down again.

Mike lies on the table for another couple of minutes as the therapist gets caught up in the other patient’s questions.

Mike looks over to the therapist, working on the other patient.

“That’s it,” he says. “I’m out of here.”

Despite his weight and his gimpy knee, Mike slides off of the table and leaves, limping as he goes.

“Mike! Mike! Where are you going?” Mary says.

“Out! I’m going out of here! I’ve had it!” Mike says.

Three months later, Margorie Kessel is taking another look at Mike’s file.

“So now we’ve got a frozen shoulder.  Probably looking at a six-figure settlement for permanent disability. And he’s still at the drugstore,” she says.

“What the heck happened to this claim?”

The Session

This scenario was originally presented at the 2014 National Workers’ Compensation and Disability Conference in Las Vegas.

As part of the discussion, panelists discussed key aspects presented in the scenario.

Panelists included Dr. Robert Goldberg, chief medical officer, Healthesystems; and Dr. Kurt Hegmann, Associate Professor, The Rocky Mountain Center for Occupational & Environmental Health. The session was moderated by Tracey Davanport, director, National Managed Care, Argonaut Insurance.

Insights from their discussion are highlighted below:

 

 

 




Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]

Cyber Resilience

No, Seriously. You Need a Comprehensive Cyber Incident Response Plan Before It’s Too Late.

Awareness of cyber risk is increasing, but some companies may be neglecting to prepare adequate response plans that could save them millions. 
By: | June 1, 2018 • 7 min read

To minimize the financial and reputational damage from a cyber attack, it is absolutely critical that businesses have a cyber incident response plan.

“Sadly, not all yet do,” said David Legassick, head of life sciences, tech and cyber, CNA Hardy.

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In the event of a breach, a company must be able to quickly identify and contain the problem, assess the level of impact, communicate internally and externally, recover where possible any lost data or functionality needed to resume business operations and act quickly to manage potential reputational risk.

This can only be achieved with help from the right external experts and the design and practice of a well-honed internal response.

The first step a company must take, said Legassick, is to understand its cyber exposures through asset identification, classification, risk assessment and protection measures, both technological and human.

According to Raf Sanchez, international breach response manager, Beazley, cyber-response plans should be flexible and applicable to a wide range of incidents, “not just a list of consecutive steps.”

They also should bring together key stakeholders and specify end goals.

Jason J. Hogg, CEO, Aon Cyber Solutions

With bad actors becoming increasingly sophisticated and often acting in groups, attack vectors can hit companies from multiple angles simultaneously, meaning a holistic approach is essential, agreed Jason J. Hogg, CEO, Aon Cyber Solutions.

“Collaboration is key — you have to take silos down and work in a cross-functional manner.”

This means assembling a response team including individuals from IT, legal, operations, risk management, HR, finance and the board — each of whom must be well drilled in their responsibilities in the event of a breach.

“You can’t pick your players on the day of the game,” said Hogg. “Response times are critical, so speed and timing are of the essence. You should also have a very clear communication plan to keep the CEO and board of directors informed of recommended courses of action and timing expectations.”

People on the incident response team must have sufficient technical skills and access to critical third parties to be able to make decisions and move to contain incidents fast. Knowledge of the company’s data and network topology is also key, said Legassick.

“Perhaps most important of all,” he added, “is to capture in detail how, when, where and why an incident occurred so there is a feedback loop that ensures each threat makes the cyber defense stronger.”

Cyber insurance can play a key role by providing a range of experts such as forensic analysts to help manage a cyber breach quickly and effectively (as well as PR and legal help). However, the learning process should begin before a breach occurs.

Practice Makes Perfect

“Any incident response plan is only as strong as the practice that goes into it,” explained Mike Peters, vice president, IT, RIMS — who also conducts stress testing through his firm Sentinel Cyber Defense Advisors.

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Unless companies have an ethical hacker or certified information security officer on board who can conduct sophisticated simulated attacks, Peters recommended they hire third-party experts to test their networks for weaknesses, remediate these issues and retest again for vulnerabilities that haven’t been patched or have newly appeared.

“You need to plan for every type of threat that’s out there,” he added.

Hogg agreed that bringing third parties in to conduct tests brings “fresh thinking, best practice and cross-pollination of learnings from testing plans across a multitude of industries and enterprises.”

“Collaboration is key — you have to take silos down and work in a cross-functional manner.” — Jason J. Hogg, CEO, Aon Cyber Solutions

Legassick added that companies should test their plans at least annually, updating procedures whenever there is a significant change in business activity, technology or location.

“As companies expand, cyber security is not always front of mind, but new operations and territories all expose a company to new risks.”

For smaller companies that might not have the resources or the expertise to develop an internal cyber response plan from whole cloth, some carriers offer their own cyber risk resources online.

Evan Fenaroli, an underwriting product manager with the Philadelphia Insurance Companies (PHLY), said his company hosts an eRiskHub, which gives PHLY clients a place to start looking for cyber event response answers.

That includes access to a pool of attorneys who can guide company executives in creating a plan.

“It’s something at the highest level that needs to be a priority,” Fenaroli said. For those just getting started, Fenaroli provided a checklist for consideration:

  • Purchase cyber insurance, read the policy and understand its notice requirements.
  • Work with an attorney to develop a cyber event response plan that you can customize to your business.
  • Identify stakeholders within the company who will own the plan and its execution.
  • Find outside forensics experts that the company can call in an emergency.
  • Identify a public relations expert who can be called in the case of an event that could be leaked to the press or otherwise become newsworthy.

“When all of these things fall into place, the outcome is far better in that there isn’t a panic,” said Fenaroli, who, like others, recommends the plan be tested at least annually.

Cyber’s Physical Threat

With the digital and physical worlds converging due to the rise of the Internet of Things, Hogg reminded companies: “You can’t just test in the virtual world — testing physical end-point security is critical too.”

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How that testing is communicated to underwriters should also be a key focus, said Rich DePiero, head of cyber, North America, Swiss Re Corporate Solutions.

Don’t just report on what went well; it’s far more believable for an underwriter to hear what didn’t go well, he said.

“If I hear a client say it is perfect and then I look at some of the results of the responses to breaches last year, there is a disconnect. Help us understand what you learned and what you worked out. You want things to fail during these incident response tests, because that is how we learn,” he explained.

“Bringing in these outside firms, detailing what they learned and defining roles and responsibilities in the event of an incident is really the best practice, and we are seeing more and more companies do that.”

Support from the Board

Good cyber protection is built around a combination of process, technology, learning and people. While not every cyber incident needs to be reported to the boardroom, senior management has a key role in creating a culture of planning and risk awareness.

David Legassick, head of life sciences, tech and cyber, CNA Hardy

“Cyber is a boardroom risk. If it is not taken seriously at boardroom level, you are more than likely to suffer a network breach,” Legassick said.

However, getting board buy-in or buy-in from the C-suite is not always easy.

“C-suite executives often put off testing crisis plans as they get in the way of the day job. The irony here is obvious given how disruptive an incident can be,” said Sanchez.

“The C-suite must demonstrate its support for incident response planning and that it expects staff at all levels of the organization to play their part in recovering from serious incidents.”

“What these people need from the board is support,” said Jill Salmon, New York-based vice president, head of cyber/tech/MPL, Berkshire Hathaway Specialty Insurance.

“I don’t know that the information security folks are looking for direction from the board as much as they are looking for support from a resources standpoint and a visibility standpoint.

“They’ve got to be aware of what they need and they need to have the money to be able to build it up to that level,” she said.

Without that support, according to Legassick, failure to empower and encourage the IT team to manage cyber threats holistically through integration with the rest of the organization, particularly risk managers, becomes a common mistake.

He also warned that “blame culture” can prevent staff from escalating problems to management in a timely manner.

Collaboration and Communication

Given that cyber incident response truly is a team effort, it is therefore essential that a culture of collaboration, preparation and practice is embedded from the top down.

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One of the biggest tripping points for companies — and an area that has done the most damage from a reputational perspective — is in how quickly and effectively the company communicates to the public in the aftermath of a cyber event.

Salmon said of all the cyber incident response plans she has seen, the companies that have impressed her most are those that have written mock press releases and rehearsed how they are going to respond to the media in the aftermath of an event.

“We have seen so many companies trip up in that regard,” she said. “There have been examples of companies taking too long and then not explaining why it took them so long. It’s like any other crisis — the way that you are communicating it to the public is really important.” &

Antony Ireland is a London-based financial journalist. He can be reached at [email protected] Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]