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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

Risk Management

The Profession: Curt Gross

This director of risk management sees cyber, IP and reputation risks as evolving threats, but more formal education may make emerging risk professionals better prepared.
By: | June 1, 2018 • 4 min read

R&I: What was your first job?

My first non-professional job was working at Burger King in high school. I learned some valuable life lessons there.

R&I: How did you come to work in risk management?

After taking some accounting classes in high school, I originally thought I wanted to be an accountant. After working on a few Widgets Inc. projects in college, I figured out that wasn’t what I really wanted to do. Risk management found me. The rest is history. Looking back, I am pleased with how things worked out.

R&I: What is the risk management community doing right?

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I think we do a nice job on post graduate education. I think the ARM and CPCU designations give credibility to the profession. Plus, formal college risk management degrees are becoming more popular these days. I know The University of Akron just launched a new risk management bachelor’s program in the fall of 2017 within the business school.

R&I: What could the risk management community be doing a better job of?

I think we could do a better job with streamlining certificates of insurance or, better yet, evaluating if they are even necessary. It just seems to me that there is a significant amount of time and expense around generating certificates. There has to be a more efficient way.

R&I: What was the best location and year for the RIMS conference and why?

Selfishly, I prefer a destination with a direct flight when possible. RIMS does a nice job of selecting various locations throughout the country. It is a big job to successfully pull off a conference of that size.

Curt Gross, Director of Risk Management, Parker Hannifin Corp.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?

Definitely the change in nontraditional property & casualty exposures such as intellectual property and reputational risk. Those exposures existed way back when but in different ways. As computer networks become more and more connected and news travels at a more rapid pace, it just amplifies these types of exposures. Sometimes we have to think like the perpetrator, which can be difficult to do.

R&I: What emerging commercial risk most concerns you?

I hate to sound cliché — it’s quite the buzz these days — but I would have to say cyber. It’s such a complex risk involving nontraditional players and motives. Definitely a challenging exposure to get your arms around. Unfortunately, I don’t think we’ll really know the true exposure until there is more claim development.

R&I: What insurance carrier do you have the highest opinion of?

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Our captive insurance company. I’ve been fortunate to work for several companies with a captive, each one with a different operating objective. I view a captive as an essential tool for a successful risk management program.

R&I: Who is your mentor and why?

I can’t point to just one. I have and continue to be lucky to work for really good managers throughout my career. Each one has taken the time and interest to develop me as a professional. I certainly haven’t arrived yet and welcome feedback to continue to try to be the best I can be every day.

R&I: What have you accomplished that you are proudest of?

I would like to think I have and continue to bring meaningful value to my company. However, I would have to say my family is my proudest accomplishment.

R&I: What is your favorite book or movie?

Favorite movie is definitely “Good Will Hunting.”

R&I: What’s the best restaurant you’ve ever eaten at?

Tough question to narrow down. If my wife ran a restaurant, it would be hers. We try to have dinner as a family as much as possible. If I had to pick one restaurant though, I would say Fire Food & Drink in Cleveland, Ohio. Chef Katz is a culinary genius.

R&I: What is the most unusual/interesting place you have ever visited?

The Grand Canyon. It is just so vast. A close second is Stonehenge.

R&I: What is the riskiest activity you ever engaged in?

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A few, actually. Up until a few years ago, I owned a sport bike (motorcycle). Of course, I wore the proper gear, took a safety course and read a motorcycle safety book. Also, I have taken a few laps in a NASCAR [race car] around Daytona International Speedway at 180 mph. Most recently, trying to ride my daughter’s skateboard.

R&I: If the world has a modern hero, who is it and why?

The Dalai Lama. A world full of compassion, tolerance and patience and free of discrimination, racism and violence, while perhaps idealistic, sounds like a wonderful place to me.

R&I: What about this work do you find the most fulfilling or rewarding?

I really enjoy the company I work for and my role, because I get the opportunity to work with various functions. For example, while mostly finance, I get to interact with legal, human resources, employee health and safety, to name a few.

R&I: What do your friends and family think you do?

I asked my son. He said, “Risk management and insurance.” (He’s had the benefit of bring-your-kid-to-work day.)

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]