Adjuster X

It Happened at Work, or Not!

By: | August 4, 2014 • 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 claim on my desk involved a veteran worker, Joe Esker, a 51-year-old warehouse supervisor for Bascom Brothers. According to the report, he felt ill and had left arm pain on the morning of the incident. An ambulance was called and he was admitted to the hospital with a heart attack.

I began my investigation at Bascom. Connie, the HR manager, told me that she got a call at 8:30 a.m. saying that Joe was in distress. She called 9-1-1 and an ambulance arrived within 10 minutes.

I asked what Joe had been doing just prior to that and she said nothing unusual. Joe’s position, I learned, was largely administrative. His duties included scheduling workers, completing paperwork, and ensuring orders were filled correctly.

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I spoke with Stan, the employee who had reported Joe’s distress. Stan said Joe arrived early and went straight to his office.

Joe was at his desk at 8:10 when Stan came in to discuss a shipment. Joe looked pale and mumbled a reply.

Stan asked if he should get help, but Joe wanted to see if it would pass. Stan came back a few minutes later, saw Joe grasping his left arm, and immediately called Connie.

I asked Connie why she submitted a workers’ comp report for Joe’s heart attack. She replied, “Because it happened at work.”

I arrived at Joe’s house later to take his statement. He readily admitted that the most physical thing he’d done that morning was get a cup of coffee.

I asked about the night before the incident. He said he was bowling. I asked how he’d felt at the time.

“To tell you the truth, I felt a bit nauseous, like I had severe heartburn,” he said.

“When I came home, I went straight to bed.”

Joe said he had no history of health issues.

Before I left, he asked, “Why the big investigation? This happened at work.”

I answered as best I could.

Joe signed a medical release, so I drove to the office of the cardiologist who’d treated Joe. The doctor hadn’t finished dictating his notes on the case yet, so I asked if a serial enzyme study had been done. The nurse said yes, but that the results wouldn’t be back for a day or two.

That was good news. Serial enzyme studies can help pinpoint the onset of a heart attack.

When the study came back, the results were as I had expected. I drove back to Bascom and told Connie that the claim wouldn’t be covered by workers’ comp.

She was stunned.

“It happened at work,” she protested.

I explained that in order to be compensable, an injury or condition must arise out of and in the course and scope of employment. There was no evidence Joe’s work brought on the heart attack. I told her the test indicated the heart attack most likely began while he was bowling.

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We got Joe and his wife on the phone.

“The serial enzyme study indicates your heart attack really began when you were bowling,” I explained as we denied the claim.

“It simply continued to progress while you were at work.”

I explained that his claim could be submitted to his major medical carrier.

After the call, Connie fretted, “I hope he doesn’t call a lawyer.” I agreed, but assured her we had a solid defense.

“This certainly taught me something I didn’t know about workers’ compensation coverage,” Connie said.

“I think Joe feels the same,” I replied.

More from Risk & Insurance

More from Risk & Insurance

2018 Risk All Stars

Stop Mitigating Risk. Start Conquering It Like These 2018 Risk All Stars

The concept of risk mastery and ownership, as displayed by the 2018 Risk All Stars, includes not simply seeking to control outcomes but taking full responsibility for them.
By: | September 14, 2018 • 3 min read

People talk a lot about how risk managers can get a seat at the table. The discussion implies that the risk manager is an outsider, striving to get the ear or the attention of an insider, the CEO or CFO.

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But there are risk managers who go about things in a different way. And the 2018 Risk All Stars are prime examples of that.

These risk managers put in gear their passion, creativity and perseverance to become masters of a situation, pushing aside any notion that they are anything other than key players.

Goodyear’s Craig Melnick had only been with the global tire maker a few months when Hurricane Harvey dumped a record amount of rainfall on Houston.

Brilliant communication between Melnick and his new teammates gave him timely and valuable updates on the condition of manufacturing locations. Melnick remained in Akron, mastering the situation by moving inventory out of the storm’s path and making sure remediation crews were lined up ahead of time to give Goodyear its best leg up once the storm passed and the flood waters receded.

Goodyear’s resiliency in the face of the storm gave it credibility when it went to the insurance markets later that year for renewals. And here is where we hear a key phrase, produced by Kevin Garvey, one of Goodyear’s brokers at Aon.

“The markets always appreciate a risk manager who demonstrates ownership,” Garvey said, in what may be something of an understatement.

These risk managers put in gear their passion, creativity and perseverance to become masters of a situation, pushing aside any notion that they are anything other than key players.

Dianne Howard, a 2018 Risk All Star and the director of benefits and risk management for the Palm Beach County School District, achieved ownership of $50 million in property storm exposures for the district.

With FEMA saying it wouldn’t pay again for district storm losses it had already paid for, Howard went to the London markets and was successful in getting coverage. She also hammered out a deal in London that would partially reimburse the district if it suffered a mass shooting and needed to demolish a building, like what happened at Sandy Hook in Connecticut.

2018 Risk All Star Jim Cunningham was well-versed enough to know what traditional risk management theories would say when hospitality workers were suffering too many kitchen cuts. “Put a cut-prevention plan in place,” is the traditional wisdom.

But Cunningham, the vice president of risk management for the gaming company Pinnacle Entertainment, wasn’t satisfied with what looked to him like a Band-Aid approach.

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Instead, he used predictive analytics, depending on his own team to assemble company-specific data, to determine which safety measures should be used company wide. The result? Claims frequency at the company dropped 60 percent in the first year of his program.

Alumine Bellone, a 2018 Risk All Star and the vice president of risk management for Ardent Health Services, faced an overwhelming task: Create a uniform risk management program when her hospital group grew from 14 hospitals in three states to 31 hospitals in seven.

Bellone owned the situation by visiting each facility right before the acquisition and again right after, to make sure each caregiving population was ready to integrate into a standardized risk management system.

After consolidating insurance policies, Bellone achieved $893,000 in synergies.

In each of these cases, and in more on the following pages, we see examples of risk managers who weren’t just knocking on the door; they were owning the room. &

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Risk All Stars stand out from their peers by overcoming challenges through exceptional problem solving, creativity, clarity of vision and passion.

See the complete list of 2018 Risk All Stars.

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