Adjuster X

House of Cards

By: | November 2, 2015 • 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]

Gregorio Molina, a night watchman, was assaulted during a break-in and was left with an incomplete spinal cord injury. The perpetrator fled the state, wasn’t apprehended and there was no possibility of subrogation.

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Litigation followed the incident, and Molina was awarded lifetime benefits. His wife was designated as his caregiver with a monthly stipend.

I got the case because my claims unit often received takeover claims from other administrators.

Of immediate concern was the claimant’s medical condition. His sedentary life and weight gain over the years resulted in high blood pressure, diabetes and elevated cholesterol.

He was also incontinent with frequent urinary tract and upper respiratory problems.

A significant problem was recurrent bedsores. Visits to the hospital were the norm.

There hadn’t been a nurse case manager assigned for years. Additionally, our state compensation act gives the claimant the right to choose their own providers.

I asked case manager Anne Spears to visit Mr. Molina. After reluctantly getting permission from his wife, Anne told me: “Their house is old and shabby, with a rickety wood deck off the second floor. Sanitary conditions were poor and the claimant sat silently in an old wheelchair.

“Mrs. Molina was guarded. Maybe that was due to her poor English. She said her husband’s day was spent on the second floor and sometimes out on the deck playing cards. I question whether she is giving him the proper care,” she said.

It was recommended Mrs. Molina attend special caregiver classes and allow bi-weekly case manager visits. Her attorney demanded cessation of case management, but when another urinary tract infection required an ER visit, I used the incident to reach out to the attorney. His belated response provided approval, but with caveats – such as bathroom renovations, an elevator and gym.

Excelsior Redesign was tasked to evaluate the house.

“You face major renovation costs with this house,” Mike Kinney told me.

“The roof is shot, leaking into the third floor and compromising the second-floor deck integrity, which is unsafe. The electrical system isn’t up to code, and cracked ceilings and walls throughout suggest damage to the floor joists and foundation.”

Including a $50,000 elevator, widened doors and a second floor emergency exit, Excelsior gave me an estimate of $485,000.

I met with my claims manager who suggested purchasing a newer single level house instead of paying for renovations. Mrs. Molina declined our offer but agreed to take classes.

For a time, all was well but then her attendance became spotty. I felt surveillance was needed.

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The investigator called to tell me that Mrs. Molina makes frequent trips to Mexico, staying for weeks. During that period, a daughter would care for her father. We heard that she was planning to garner rental income from the restored second floor.

I wrote to the Molinas’ attorney advising him that the limited renovation was off the table.

Absent adherence, we informed the attorney that we would motion the court to have Mr. Molina admitted to a care facility, thus ending Mrs. Molina’s caregiver stipend.

Surprisingly a favorable answer was received. Compliance improved, case management was reinstated and a limited modification was completed.

More from Risk & Insurance

More from Risk & Insurance

Risk Management

The Profession

As a professor of business, Jack Hampton knows firsthand the positive impact education has on risk managers as they tackle growing risks.
By: | April 9, 2018 • 4 min read

R&I: Who is your mentor and why?

Ellen Thrower, president (retired), The College of Insurance, introduced me to the importance of insurance as a component of risk management. Further, she encouraged me to explore strategic and operational risk as foundation topics shaping the role of the modern risk manager.

Chris Mandel, former president of RIMS and Risk Manager of the Year, introduced me to the emerging area of enterprise risk management. He helped me recognize the need to align hazard, strategic, operational and financial risk into a single framework. He gave me the perspective of ERM in a high-tech environment, using USAA as a model program that later won an excellence award for innovation.

Bob Morrell, founder and former CEO of Riskonnect, showed me how technology could be applied to solving serious risk management and governance problems. He created a platform that made some of my ideas practical and extended them into a highly-successful enterprise that served risk and governance management needs of major corporations.

R&I: How did you come to work in this industry?

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From a background in corporate finance and commercial banking, I accepted the position of provost of The College of Insurance. Recognizing my limited prior knowledge in the field, I became a student of insurance and risk management leading to authorship of books on hazard and financial risk. This led to industry consulting, as well as to the development of graduate-level courses and concentrations in MBA programs.

R&I: What was your first job?

The provost position was the first job I had in the industry, after serving as dean of the Seton Hall University School of Business and founding The Princeton Consulting Group. Earlier positions were in business development with Marine Transport Lines, consulting in commercial banking and college professorships.

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

Creating a risk management concentration in the MBA program at Saint Peter’s, co-founding the Russian Risk Management Society (RUSRISK), and writing “Fundamentals of Enterprise Risk Management” and the “AMA Handbook of Financial Risk Management.”

A few years ago, I expanded into risk management in higher education. From 2017 into 2018, Rowman and Littlefield published my four books that address risks facing colleges and universities, professors, students and parents.

Jack Hampton, Professor of Business, St. Peter’s University

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

The Godfather. I see it as a story of managing risk, even as the behavior of its leading characters create risk for others.

R&I: What is your favorite drink?

Jameson’s Irish whiskey. Mixed with a little ice, it is a serious rival for Johnny Walker Gold scotch and Jack Daniel’s Tennessee whiskey.

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

Mount Etna, Taormina, and Agrigento, Sicily. I actually supervised an MBA program in Siracusa and learned about risk from a new perspective.

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

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Army Airborne training and jumping out of an airplane. Fortunately, I never had to do it in combat even though I served in Vietnam.

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

George C. Marshall, one of the most decorated military leaders in American history, architect of the economic recovery program for Europe after World War II, and recipient of the 1953 Nobel Peace Prize. For Marshall, it was not just about winning the war. It was also about winning the peace.

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

Sharing lessons with colleagues and students by writing, publishing and teaching. A professor with a knowledge of risk management does not only share lessons. The professor is also a student when MBA candidates talk about the risks they manage every day.

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

Sensitizing for-profit, nonprofit and governmental agencies to the exposures and complexities facing their organizations. Sometimes we focus too much on strategies that sound good but do not withstand closer examination. Risk managers help organizations make better decisions.

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

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Developing executive training programs to help risk managers assume C-suite positions in organizations. Insurance may be a good place to start but so is an MBA degree. The Risk and Insurance Management Society recognizes the importance of a wide range of risk knowledge. Colleges and universities need to catch up with RIMS.

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

Cyber risk and its impact on hazard, operational and financial strategies. A terrorist can take down a building. A cyber-criminal can take down much more.

R&I: What does your family think you do?

My family members think I’m a professor. They do not seem to be too interested in my views on risk management.




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