A new claim slides across an adjuster’s desk. The claimant suffered whiplash in a car accident, is reporting dizziness, headaches and blurred vision, and is alleging traumatic brain injury. He is seeking a life care plan to help him cope, which means more doctor visits, more tests, more treatments and higher claims costs.
Claims like this are becoming more and more common. Life care plans have always gone hand in hand with catastrophic traumatic brain injuries (TBI), where severe blows to the head left victims with decreased brain function. But TBI claims are now being asserted in less serious, non-contact accidents — like slips and falls and whiplash from fender benders — and plaintiffs’ attorneys are increasingly calling for life care plans to treat them.
“We’re seeing an uptick in allegations of traumatic brain injury and calls for extra care that drive up the cost of litigated claims,” said John Watkins, SVP, Complex Claims at Liberty Mutual Insurance.
Liberty Mutual’s John Watkins discusses the increase in both traumatic brain injury allegations and requests for life care plan in the complex claims management space.
Increased public awareness has helped drive up the frequency of TBI claims. The high-profile concussion lawsuit and settlement between former professional football players and the NFL, as well as publicized cases of chronic traumatic encephalopathy (CTE) have drawn attention to the dangers of TBIs. As public awareness rises, so do the number of allegations and claims.
“We saw a similar wave of claims connected to carpal tunnel syndrome,” Watkins said. “Back when that was something new, we saw an explosion of carpal tunnel claims. We’re now seeing a wave of TBI claims with the added component of life care plans. Again, our challenge is to identify legitimate claims and get people the appropriate treatment.”
The subjectivity of brain injury symptoms makes them easy to claim, but difficult to verify. Dizziness, light-headedness, blurred vision, ringing in the ears and difficulty concentrating can be signs of a mild or moderate brain injury — temporary symptoms that can fade as the brain heals. Or, these symptoms could be indicative of a severe injury with lasting damage.
But with no way to objectively measure these symptoms, they are unreliable indicators of severity.
MRIs and CAT scans can typically detect internal damage and bleeding that would be associated with a severe TBI, but sometimes, brain damage may not be visually present. Instead, doctors conduct other tests to measure brain function and the impact of an injury. There is a wide degree of variability involved in these post injury tests and they may only tell a portion of the story. In many cases, a brain function test is not administered immediately after an injury, but several weeks or even months later.
Why traumatic brain injury claims can be challenging.
“Most individuals don’t have documented baseline tests of brain function and that makes it much more difficult to measure any changes after an injury. That’s why much of the time, a diagnosis is based on subjective symptoms like headaches, dizziness, or blurred vision,” Watkins said.
“The brain is a remarkable organ that is capable of healing itself,” Watkins said. “If someone has a concussion and experiences a marked decline in brain function months after an accident, that’s a sign to study that claim further.”
Liberty Mutual takes a three-pronged approach to managing TBI claims and other complex claims.
First and foremost is staying on top of trends. Big Data plays an important role and helps to identify pockets where the claims experience is outside the norm. For example, if a number of TBI claims are concentrated in specific jurisdictions that could indicate that the uptick in frequency or severity may be driven by reasons other than broader market forces. These claims will require more thorough investigation.
How insurers can help risk managers with traumatic brain injury claims and control costs.
The second prong of the claims management approach is Liberty Mutual’s in-house medical staff.
“We made the conscious choice to invest in having doctors and nurses as part of our claims team. This medical expertise not only helps us on the workers compensation side, it also helps with TBIs and other complex liability claims. Our regional medical directors and nurses know what questions to ask and if the recommended treatment follows evidence-based guidelines. They can respond to any questions our claims adjusters have in the moment, which enables us to address claims more efficiently,” Watkins said.
The third prong of Liberty Mutual’s approach is its dedicated complex claims team. Adjusters specialize in these types of claims and receive advanced training in TBIs so they know how to recognize them early on.
Liberty Mutual has also created an internal traumatic brain injury “playbook,” which helps adjusters understand the injury, symptoms, and how to manage these claims so that they can have productive discussions with treating medical professionals.
“We saw a similar wave of claims connected to carpal tunnel syndrome. Back when that was something new, we saw an explosion of carpal tunnel claims. We’re now seeing a wave of TBI claims with the added component of life care plans. Again, our challenge is to identify legitimate claims and get people the appropriate treatment.”
— John Watkins, SVP, Complex Claims, Liberty Mutual Insurance
“From our experience we know that early intervention is critical to driving better outcomes for injured people. The first thing an adjuster will do is check for that baseline test. We may be able to get earlier MRIs or brain function tests from the claimant’s medical records. Now, many schools require baseline brain function tests of student athletes, so as the population ages, these early baselines records will become more and more common,” Watkins said.
An adjuster may also request a recorded statement from the claimant soon after the injury that details what symptoms he or she is experiencing. This statement can act as a baseline if there is no brain function test or MRI on record.
Liberty Mutual’s claims staff works hand in hand with its medical experts. Round table discussions give both teams the opportunity to talk through cases and develop action plans. These interactions, paired with additional training and internal resources, enable adjusters to develop expertise in niche areas where trends are developing.
“When our adjusters are cognizant of the trends, follow the playbook and utilize the expertise of our medical staff, we derive better outcomes,” Watkins said. “Our goal is to ensure that that each claimant receives the appropriate care and treatment plan he or she deserves.”
To learn more about Liberty Mutual, visit https://business.libertymutualgroup.com/business-insurance/claims-overview.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty Mutual Insurance. The editorial staff of Risk & Insurance had no role in its preparation.