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Unhinged

The co-morbidities of age and weight and a stubborn failure to adhere to his physical therapy regimen spell trouble for an injured, middle-aged construction foreman.
By: | April 19, 2016 • 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:

 

Heading South

It’s five weeks since the day Reggie first felt that twinge in his knee. The pain is still not so great that Reggie can’t live with it, but he’s getting a little tired of it.

After work one day, Reggie is having beers with Smitty Cheeks, one of the company’s mid to long-range truckers, who’s done driving for the week and will be spending the weekend in Memphis.

Smitty and Reggie are engaged in game of 8-Ball at their local blues and barbecue joint. Smitty slams the 8 ball into the corner pocket, winning the game.

“My game,” says Smitty.

Reggie eyes the waitress delivering food to their nearby booth.

“Good thing,” Reggie says. “ ’Cause our food is here.”

Partner

Partner

The two are tearing into some serious barbecue when Reggie notices Smitty pulling a pill from a vial in his pocket. Reggie’s already had a couple of beers, which makes him a little bolder.

“Watcha’ got there partner?” Reggie says.

“Vicodin,” Smitty says.

“My back’s a mess and I’ve been taking these Vicodins for a while. They help a good deal. Probably not best to drink and use these, but hey, whatever gets you through the night,” Smitty says with a beery wink.

Reggie pauses and then blurts out.

“Could you hook me up with a few of those? I’ve been having some aches and pains myself.”

Smitty pauses, then very efficiently strips the smoked meat off of a turkey wing.

“I can get you all you need buddy and the price is right,” he says, his lips smeared with barbecue sauce and this time not smiling.

The next day, Reggie, whose become more inactive and out of condition since his knee injury, is coming out of the bathroom at home with a towel around his waist.

He’s limping worse than he has been recently. The knee has begun to lock on occasion and feels like it might be giving out. His wife Arlene addresses him.

“When are you going to see a doctor?” she says to him with a worried expression on her face.

“I really don’t know,” says Reggie.

“I really think you should,” she says. “You don’t know what’s going on there and you should at least get it checked out.”

Reggie pauses, embarrassed. Arlene is looking at him compassionately and it softens his defenses.

“I tweaked my knee at work a while back. Tell you what, I’ll tell my boss on Monday and go see somebody.”

“Good,” Arlene says.  “You don’t want to go too long before figuring out what’s up.”

RSL_2015

Reggie tells his supervisor about his injury. Reggie’s injury is in turn reported to the company’s insurance carrier. But neither the claims adjuster or the employer discuss the idea of Reggie being offered modified duty.

Reggie is referred to an in-network physician, an occupational medicine specialist. The Occ-Med prescribes an anti-inflammatory for Reggie. He also orders an MRI for him and gives him a prescription for four sessions of Physical Therapy and orders him a hinge knee brace, due to the “giving out” feeling Reggie has reported in his knee.

The Occ-Med specialist gets the MRI results, which reveals a tear. Without calling Reggie into have another look at him or gauge how he’s done in therapy, the Occ-Med refers Reggie to an orthopedic surgeon.

Reggie is in the surgeon’s office looking at the MRI results with the surgeon when he gets the news.

“The MRI scan reveals a 4 mm acute medial meniscus tear, Reggie,” the surgeon says.

“We’re going to want to repair this,” he continues.

“You mean surgery?”

“Yes. I don’t want to let this sort of thing go in a man your age,” the surgeon says, patting Reggie on the shoulder compassionately.

Mollified by the surgeon’s kindly tone, Reggie doesn’t question the decision or seek a second opinion.

Reggie doesn’t think to ask about a less invasive approach, like more physical therapy, and the surgeon doesn’t bring it up. The surgeon puts in a request for surgery, which is approved by the adjustor with no follow up or questioning as to its necessity.

Reggie undergoes preauthorized, minor arthroscopic surgery and is initially given six weeks off of work under the direction of the surgeon.

The carrier’s claims adjustor makes a note of the surgery but doesn’t contact the employer or Reggie to check in on his condition.

“It’s a pretty minor procedure,” she tells herself while alternating between looking at her computer monitor, where the details of Reggie’s case are displayed, and checking her cell phone.

Then her phone rings.

“This is Janice,” she says, and clicks to another screen on her computer. Reggie’s case is out of sight, out of mind.

No one from Reggie’s company checks in with him to discuss the future possibility of modified duty or to check on his overall welfare.

The Wheels Come Off

It’s one week post-op and Reggie pays a visit to the surgeon for a wound check.

“Let’s have a look here,” the surgeon says, gently peeling off the adhesive bandage.

“Looking good,” he says.

“Good,” Reggie says.

The surgeon swabs Reggie’s knee with some antiseptic and distracts Reggie as he pulls out the sutures with a discussion about planning for the way forward.

“So, I’m going to give you a prescription for therapy. I want to see you do at least 12 visits to work on regaining full range of motion in the knee and getting your strength back.”

“Got it,” said Reggie.

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“How’s your pain?” the surgeon says.

“It hurts, no doubt,” Reggie said.

“Well let me know if you need more pain medication,” the surgeon says.

“I just might do that,” Reggie says before gingerly slipping down from the table.

***

It’s a week later and Reggie is sitting on the couch at home with the channel changer in his hand and his leg up.

Reggie checks his iPhone, scanning his e-mail inbox.

“Have you heard anything about your physical therapy appointment?” Arlene says from the kitchen where’s she’s pouring some tea for her and Reggie.

“Nothing,” Reggie says.

“I think I’m going to call them,” she says. “We need to get you into physical therapy.”

“Go ahead. I doubt they’ll call you back,” Reggie says. He’s not out of it but his manner is resigned and sluggish.

“It hasn’t been approved or processed yet by the insurance company.”

“Has anybody from your company ever contacted you?” Arlene says.

“Nope. But I’m still getting my workers’ comp checks, I guess I can be thankful for that,” Reggie says.

Reggie palms a pain pill from a vial and swallows it with a sip of water. Arlene can’t see him do this from her vantage point in the kitchen.

“I don’t like it, they should be in touch,” Arlene says.

“You’re probably right,” Reggie says, over his shoulder, taking a break from look at the television.

***

It’s another week before Reggie gets into therapy. The therapist greets Reggie as he’s ushered into the treatment area.

“Hi, I’m Maggie,” the therapist says. “Come on over to this table and lie down. I want to put some electrical stimulation on your knee and then we’ll get to work on it a little bit.”

Reggie walks over to the table, limping noticeably.

“You had surgery when?” Maggie the therapist says.

“Three weeks ago,” Reggie says.

“Hmmm, you’re late getting in here,” the therapist says.

“After we get through our work here today, I’m going to give you some home exercises to help you get caught up. We need to keep this knee moving and build your strength back up,” she says.

***

We cut forward to see the therapist working on Reggie’s knee. She flexes the knee slightly and Reggie almost jumps off of the table.

“This joint is stiff,” the therapist says.

“It sure is,” Reggie says.

Reggie’s reacting to the pain and eyes the therapist warily.

Reggie’s back at home and back in front of the television set. This time he’s got the pain medication bottle out in full view.

Arlene comes in carrying some groceries.

“Have you done your therapy exercises today?” she says.

“Not yet,” Reggie says.

She eyes the vial of pills on the table next to Reggie.

“I thought you were done with those,” she says.

“I’m not taking that many of them,” Reggie says. “And I did move. I went to the bathroom.”

Arlene just looks at him. She’s concerned but clearly doesn’t want to start an argument.

Without another word, Arlene heads to the kitchen with the groceries.

It’s five weeks since Reggie’s last visit to the orthopedic specialist and he uses a cane to get into the examination room. The use of the cane was approved by the adjustor.

The surgeon enters the room and sees the cane propped next to Reggie as Reggie sits on the examination table.

The surgeon is very alarmed.

“What’s the cane for?” he says. “I didn’t order you one.”

“I need it to walk,” Reggie says. “My knee’s still killing me and it’s hard to move it.”

“Where’d you get it, the cane?” the surgeon says, clearly disturbed.

“The therapist gave it to me,” Reggie says.

The surgeon quickly scans his electronic pad, looking for the report from the therapist.

“You had six visits. You were late getting in there but you had six visits. Although you should have had 12,” the doctor says, not quite panicking but clearly unnerved.

“You should have been going twice a week.”

Reggie ignores him.

“You said I could have more pain pills if I needed them, right?”

“What?” the doctor says, jarred that Reggie is ignoring him and taking up another subject.

“Yes I said that but I didn’t think you’d…” the doctor says before Reggie interrupts him.

“I’m gonna’ need more pain pills,” Reggie says with an edge.

The doctor says nothing. He’s at a loss.

“Doctor, I want more pain pills,” Reggie says.

The Session

This scenario was originally presented at the 2015 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. Jeffrey Sugar, Associate Medical Director, Sharp Rees-Stealy Medical Group. The session was moderated by Tracey Davanport, director, National Managed Care, Argo Group.

Insights from their discussion are highlighted below:

 

 

 




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

R&I Profile

Achieving Balance

XL Catlin’s Denise Balan stays calm and focused when faced with crisis.
By: | January 10, 2018 • 6 min read

In the high-stress scenario of kidnap or ransom, the first image that comes to mind isn’t necessarily a yoga mat — at least, not for most.

But Denise Balan, senior VP and head of U.S. kidnap & ransom, XL Catlin, who practices yoga every day, would swear by it.

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“I looked at these opposing aspects of my life,” she said. “Yoga is about focus, balance, clarity of intent. In a moment of stress, how do you respond? The more clarity and calmness you maintain, the better positioned you are to provide assistance in moments of crisis.

“Nobody wants to be speaking to a frenetic person when either dealing with a dangerous situation or planning for prevention of a situation,” she added.

“There’s a poem by [Rudyard] Kipling on that,” added Balan’s colleague Ben Tucker. “What it boils down to is: If you can remain calm, you can manage through a crisis a lot better.”

Tucker, who works side by side with Balan as head of U.S. terrorism and political violence, XL Catlin, has seen how yoga influences his colleague.

“The way Denise interacts with stakeholders in this process — she is very professional and calm in the approach she takes.”

Yin and Yang

Sometimes seemingly opposite or contrary forces may actually be complementary and interconnected. In Balan’s life, yoga and K&R have become her yin and yang.

She entered the insurance world after earning a juris doctor degree and practicing law for a few years. The switch came, she said, when Balan realized she wasn’t enjoying her time as a commercial litigator.

Denise Balan, senior VP and head of U.S. kidnap & ransom, XL Catlin

In her new role, she was able to use her legal background to manage litigation at AIG, where her transition from law to insurance took place. She started her insurance career in the environmental sector.

In a chance meeting in 2007, Balan met with crisis management underwriters who told her about kidnap and ransom products.

She was hooked.

Because of her background in yoga, Balan liked the crisis management side of the job. Being able to bring the calmness and clearness of intent she practiced during yoga into assisting clients in planning for crisis management piqued her interest.

She then joined XL Catlin in July 2013, where she built the K&R team.

As she became more immersed in her field, Balan began to notice something: The principles she learned in yoga were the same principles ex-military and ex-law enforcement practiced when called to a K&R-related crisis.

She said, “They have a warrior mentality — focus, purpose, strength and logic — and I would say yoga is quite similar in discipline.”

“K&R responders have a warrior mentality — focus, purpose, strength and logic — and I would say yoga is quite similar in discipline.” — Denise Balan, senior VP and head of U.S. kidnap & ransom, XL Catlin

Many understand yoga to be, in itself, one type of meditation, but yoga actually encompasses a group of physical, mental and spiritual practices. Each is a discipline. Some forms of yoga focus on movement and breathing, others focus on posture and technique. Some yoga is meant to relax the mind and create a sense of calmness; other yoga types make participants sweat.

After having her second child and working full-time, Balan wanted to find something physical and relaxing for herself; a friend suggested yoga. During her first lesson, Balan said she was enamored with it.

“I felt like I’d done it all my life.”

She dove into the philosophy of yoga, adopting the practice into her daily routine. Every morning, whether Balan is in her Long Island home or on a business trip, she pulls out her yoga mat to practice.

“I always travel with my mat,” she said. “Daily practice is the simplest form of connection to routine to maintain my balance — physically and mentally.”

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She said the strangest place she has ever practiced was in Lisbon. She was on a very narrow balcony with a bird feeder swarming with sparrows overhead.

After years of studying and practicing, Balan is considered a yogi — someone who is highly proficient in yoga. She attends annual retreats with her yoga group, where she is able to rejuvenate, ready to tackle any K&R event when she returns.

In 2016, Balan visited Tuscany, Italy, where she learned the practice of yoga nidra, a very deep form of meditation. It’s described as the “going-to-sleep stage” — a type of yoga that brings participants to a state of consciousness between waking and sleeping.

“It awakens a different part of your brain,” Balan commented. “Orally describing it doesn’t quite do it justice. One has to practice Nidra to fully understand the effect it has on your being.”

Keeping a level head during a crisis is key in their line of business, Tucker said. He can attest to the benefit of having a yogi on board.

“I’ve seen her run table-top exercises where there is this group of people in a room and they run an exercise, a simulation of a kidnap incident. Denise is very committed to what we’re doing,” said Tucker.

“She brings that energy. She doesn’t get flustered by much.”

Building a K&R Program

When Balan joined XL Catlin, she was tasked with creating the K&R team.

Balan during a retreat in Sicily, Italy, 2017

She spent time researching and analyzing what clients would want in their K&R coverage. What stuck out most to Balan was the fact that, in these situations, the decision to purchase kidnap and ransom cover is rarely made because of desire for reimbursement of money.

“I asked why people buy this type of coverage. The answer was for the security responders,” she said.

“These are the people who sit with the family. They’re similar to psychologists or priests,” Balan further explained. “Corporations can afford to pay ransom. They buy [K&R] because it gives them access to these trained and dedicated professionals who not only provide negotiation advice, but actually sit with a victim’s family, engaging deep levels of emotional investment.”

“I’ve learned to appreciate all moments in life — one at a time. The ability to think clearly and calmly guides my work, my practice and my personal life.” — Denise Balan, senior VP and head of U.S. kidnap & ransom, XL Catlin

Balan described these responders as people having total clarity of purpose, setting their intentions to resolve a crisis — a practice at the very heart of yoga. She knew XL Catlin’s new kidnap program would put stock in their responders.

“I’ve worked closely with the responders to better understand what they can do for our clientele. These are the people who run into danger — warrior hearts married to dedication to our clients’ best interests.”

But K&R is more than fast-paced crisis and quick thinking; Balan also spent a good deal of time writing the K&R form and getting the company’s resources in order. This was a huge task to tackle when creating the program from the ground up.

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“A lot of my day-to-day is speaking with brokers and finding ways to enhance our product,” she said.

After a few months, she was able to hire the company’s first K&R underwriter. From there, the program has grown. It’s left her feeling professionally rewarded.

“People don’t often get that opportunity to build something up from scratch,” she said. “It’s been an amazing experience — rewarding and fun.”

“She brings groups of people together,” said Tucker. “She’s created a positive environment.”

Balan’s yogi nature extends beyond the office walls, too. Her pride and joy, she said, are her kids. And while it may seem like two large parts of her life are opposite in nature, Balan’s achieved balance through her passions.

“[Yoga] has given me the ability to see beyond only one aspect of any situation” she said. “I’ve learned to appreciate all moments in life — one at a time. The ability to think clearly and calmly guides my work, my practice and my personal life.” &

Autumn Heisler is a staff writer at Risk & Insurance. She can be reached at [email protected]