Adjuster X

A Tale of Turbulence

By: | November 1, 2013 • 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 loss report for Gloria, a 47-year-old flight attendant, noted a left-hand strain from securing a beverage cart during air turbulence, and also carpal tunnel syndrome. Gloria had received initial treatment at a 24-hour clinic, but the clinic wouldn’t provide details without a signed HIPAA release.

The flight log confirmed episodic turbulence. A co-worker saw Gloria’s cart roll backwards, but never saw it touch her.

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Within two days, the employer received an attorney letter of representation, and a request for payment of temporary total disability. We acknowledged the representation and asked Gloria to sign a HIPAA release. I assigned a nurse case manager but she didn’t get responses from the attorney.

Our claim representative learned Gloria had three group claims involving lost time related to stress due to a divorce and a child’s car accident. The ISO query of prior accidents ran eight pages covering nine years, including three falls in retail stores with multiple body parts injured; a fall on ice in a parking lot with neck, arm and leg injuries; and four back, hand and knee claims when she worked for other airlines. Prior to this incident, she had three workers’ compensation claims with her current employer involving back and hands. Follow-up requests for more detailed information were sent to the other carriers noted on the reports.

By now, the first lost-time payment was due. But all we knew was that a cart had rolled and may or may not have struck Gloria. The attorney was unresponsive. I decided not to issue a check, citing lack of substantiating medical information. Letters were sent to Gloria, her attorney and the employer. It was another month until we received the HIPAA release and permission for nurse case management.

The case manager’s report described an individual who was focused on being injured and took a lot of pain medication. Gloria had been hospitalized more than two dozen times — half of those involved hand or knee surgery. The case manager felt she had psychosocial impediments to returning to work. She was taking high doses of antidepressants and had a victim mentality. Gloria felt certain she needed carpal tunnel surgery, which she blamed on the airline’s equipment. The case manager suggested medical evaluations on the causal relationship of carpal tunnel and a psychologist referral.

Our attorney recommended that we pay the accrued indemnity benefits for the hand injury to avoid penalties and fines. But he deferred judgment on the carpal tunnel syndrome. We agreed Gloria appeared to have psychological issues.

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The reports we received painted a disturbing picture. Hospital records cited 911 calls to Gloria’s home as a result of injuries to her hands while peeling potatoes. On another, she had fallen, admitting use of sleep medications and pain relievers. Surveillance showed her performing manual labor at her house.

All parties agreed that Gloria was setting the stage for a finding of permanent and total disability. Although we could have fought to defeat the claim, we felt that settlement was the best fiscal strategy. By leveraging the medical and psychological reports as well as the surveillance, we were able to settle the case. We took credit for indemnity paid and agreed to three years of future comp. It wasn’t a dream ending, but at least it wasn’t even more of a nightmare.

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The R&I Editorial Team can be reached at [email protected]