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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.

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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.
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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.

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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.”
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Off the Rails

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

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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?”
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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]

Property

Insurers Take to the Skies

This year’s hurricane season sees the use of drones and other aerial intelligence gathering systems as insurers seek to estimate claims costs.
By: | November 1, 2017 • 6 min read

For Southern communities, current recovery efforts in the wake of Hurricane Harvey will recall the painful devastation of 2005, when Katrina and Wilma struck. But those who look skyward will notice one conspicuous difference this time around: drones.

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Much has changed since Katrina and Wilma, both economically and technologically. The insurance industry evolved as well. Drones and other visual intelligence systems (VIS) are set to play an increasing role in loss assessment, claims handling and underwriting.

Farmers Insurance, which announced in August it launched a fleet of drones to enhance weather-related property damage claim assessment, confirmed it deployed its fleet in the aftermath of Harvey.

“The pent-up demand for drones, particularly from a claims-processing standpoint, has been accumulating for almost two years now,” said George Mathew, CEO of Kespry, Farmers’ drone and aerial intelligence platform provider partner.

“The current wind and hail damage season that we are entering is when many of the insurance carriers are switching from proof of concept work to full production rollout.”

 According to Mathew, Farmers’ fleet focused on wind damage in and around Corpus Christi, Texas, at the time of this writing. “Additional work is already underway in the greater Houston area and will expand in the coming weeks and months,” he added.

No doubt other carriers have fleets in the air. AIG, for example, occupied the forefront of VIS since winning its drone operation license in 2015. It deployed drones to inspections sites in the U.S. and abroad, including stadiums, hotels, office buildings, private homes, construction sites and energy plants.

Claims Response

At present, insurers are primarily using VIS for CAT loss assessment. After a catastrophe, access is often prohibited or impossible. Drones allow access for assessing damage over potentially vast areas in a more cost-effective and time-sensitive manner than sending human inspectors with clipboards and cameras.

“Drones improve risk analysis by providing a more efficient alternative to capturing aerial photos from a sky-view. They allow insurers to rapidly assess the scope of damages and provide access that may not otherwise be available,” explained Chris Luck, national practice leader of Advocacy at JLT Specialty USA.

“The pent-up demand for drones, particularly from a claims-processing standpoint, has been accumulating for almost two years now.” — George Mathew, CEO, Kespry

“In our experience, competitive advantage is gained mostly by claims departments and third-party administrators. Having the capability to provide exact measurements and details from photos taken by drones allows insurers to expedite the claim processing time,” he added.

Indeed, as tech becomes more disruptive, insurers will increasingly seek to take advantage of VIS technologies to help them provide faster, more accurate and more efficient insurance solutions.

Duncan Ellis, U.S. property practice leader, Marsh

One way Farmers is differentiating its drone program is by employing its own FAA-licensed drone operators, who are also Farmers-trained claim representatives.

Keith Daly, E.V.P. and chief claims officer for Farmers Insurance, said when launching the program that this sets Farmers apart from most carriers, who typically engage third-party drone pilots to conduct evaluations.

“In the end, it’s all about the experience for the policyholder who has their claim adjudicated in the most expeditious manner possible,” said Mathew.

“The technology should simply work and just melt away into the background. That’s why we don’t just focus on building an industrial-grade drone, but a complete aerial intelligence platform for — in this case — claims management.”

Insurance Applications

Duncan Ellis, U.S. property practice leader at Marsh, believes that, while currently employed primarily to assess catastrophic damage, VIS will increasingly be employed to inspect standard property damage claims.

However, he admitted that at this stage they are better at identifying binary factors such as the area affected by a peril rather than complex assessments, since VIS cannot look inside structures nor assess their structural integrity.

“If a chemical plant suffers an explosion, it might be difficult to say whether the plant is fully or partially out of operation, for example, which would affect a business interruption claim dramatically.

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“But for simpler assessments, such as identifying how many houses or industrial units have been destroyed by a tornado, or how many rental cars in a lot have suffered hail damage from a storm, a VIS drone could do this easily, and the insurer can calculate its estimated losses from there,” he said.

In addition,VIS possess powerful applications for pre-loss risk assessment and underwriting. The high-end drones used by insurers can capture not just visual images, but mapping heat, moisture or 3D topography, among other variables.

This has clear applications in the assessment and completion of claims, but also in potentially mitigating risk before an event happens, and pricing insurance accordingly.

“VIS and drones will play an increasing underwriting support role as they can help underwriters get a better idea of the risk — a picture tells a thousand words and is so much better than a report,” said Ellis.

VIS images allow underwriters to see risks in real time, and to visually spot risk factors that could get overlooked using traditional checks or even mature visual technologies like satellites. For example, VIS could map thermal hotspots that could signal danger or poor maintenance at a chemical plant.

Chris Luck, national practice leader of Advocacy, JLT Specialty USA

“Risk and underwriting are very natural adjacencies, especially when high risk/high value policies are being underwritten,” said Mathew.

“We are in a transformational moment in insurance where claims processing, risk management and underwriting can be reimagined with entirely new sources of data. The drone just happens to be one of most compelling of those sources.”

Ellis added that drones also could be employed to monitor supplies in the marine, agriculture or oil sectors, for example, to ensure shipments, inventories and supply chains are running uninterrupted.

“However, we’re still mainly seeing insurers using VIS drones for loss assessment and estimates, and it’s not even clear how extensively they are using drones for that purpose at this point,” he noted.

“Insurers are experimenting with this technology, but given that some of the laws around drone use are still developing and restrictions are often placed on using drones [after] a CAT event, the extent to which VIS is being used is not made overly public.”

Drone inspections could raise liability risks of their own, particularly if undertaken in busy spaces in which they could cause human injury.

Privacy issues also are a potential stumbling block, so insurers are dipping their toes into the water carefully.

Risk Improvement

There is no doubt, however, that VIS use will increase among insurers.

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“Although our clients do not have tremendous experience utilizing drones, this technology is beneficial in many ways, from providing security monitoring of their perimeter to loss control inspections of areas that would otherwise require more costly inspections using heavy equipment or climbers,” said Luck.

In other words, drones could help insurance buyers spot weaknesses, mitigate risk and ultimately win more favorable coverage from their insurers.

“Some risks will see pricing and coverage improvements because the information and data provided by drones will put underwriters at ease and reduce uncertainty,” said Ellis.

The flip-side, he noted, is that there will be fewer places to hide for companies with poor risk management that may have been benefiting from underwriters not being able to access the full picture.

Either way, drones will increasingly help insurers differentiate good risks from bad. In time, they may also help insurance buyers differentiate between carriers, too. &

Antony Ireland is a London-based financial journalist. He can be reached at [email protected]