Risk Scenarios Live!

The Defeat of Lupe

A routine back injury evolves into chronic pain.
By: | November 18, 2013 • 8 min read
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:


The Aftermath

 At 58 years old, Lupe feels she has little to complain about. She’s able to earn a meaningful income for her family and provide for the two grandchildren she’s been left to raise. The workdays are long, though, and at five foot three and 145 pounds, Lupe could probably be a little more fit.

But there is work to do and a family to feed. Lupe has little time for vanities.

When Lupe slips in the bathroom and injures her back, two things run through her mind immediately. This is the worst pain she has ever felt outside of childbirth, and she must tell no one about it. Lupe has seen coworkers who were injured and lost their jobs. Not to mention the fact that as a first generation immigrant, Lupe has unfounded fears about discrimination and the threat of deportation, even though she is here legally.



Before she leaves work that night, Lupe downs a couple of Ibuprofen. The tablets help a little, which gives her hope that she can ride this out.

But the pain wakes her the next morning before the rising sun does. The pain is deep, persistent, and throbbing.

Standing helps, so Lupe takes another couple tablets of Ibuprofen, thinking she can ward off the pain. But walking to catch the bus to work is a real challenge. The pain dogs Lupe but she soldiers on.

Within a week the pain is too much. Pushing aside her cultural fears, Lupe visits a walk-in clinic.

ScenariosLive_Healthesystems“I want to work,” Lupe tells the doctor at the clinic.

“Go ahead and do so,” she says. “But please take it easy, don’t push yourself.”

“I won’t … too hard,” she says with a game smile.

The physician at the clinic prescribes Vicodin, Ibuprofen and Soma for Lupe.

Lupe tries to manage her pain with the medications and restraining her activities at work. Her co-workers try to help shield her from managerial scrutiny. But it wouldn’t take much to see that she is in serious pain.

Three weeks after her injury, Lupe is not only having extreme back pain but is also having a burning sensation in her groin and right upper leg. Scared by the expanding area of pain she is experiencing, Lupe reports her injury to her workplace and her HR specialist refers her to the hotel’s occupational medicine specialist.

The occupational medicine specialist takes X-rays of Lupe’s back and increases her opioid dose from Vicodin to Norco and moves her off of Ibuprofen and onto Celebrex. His diagnosis is that Lupe has an acute back sprain.

The claims handler, on the occupational medicine specialist’s recommendation, also authorizes six weeks of physical therapy for Lupe.

The Treatment


Lupe experiences a two-week delay in getting her physical therapy authorized.

But once she gets there, one visit to physical therapy is enough for Lupe. She doesn’t understand the therapist’s instructions due to a language barrier and isn’t relaxed enough to be manipulated in any way.

“You have to relax Lupe, I’m not going to hurt you,” the therapist says.

Scenario_TheToxicBalloon“Owww!” she says when the therapist attempts to work on her back.

All Lupe knows is that she has been hurt when she was told she wouldn’t be. In pain, fearful, and now angry, Lupe pushes herself upright, grabs her shoes and walks out of the room, limping as she goes.

“I don’t want anybody touching me,” she says to herself on the bus ride home.

Lupe’s pain persists to the point that nine weeks after her injury, her occupational medicine specialist orders an MRI for her. His diagnosis after seeing the results is that she has persistent low back pain. The MRI reveals bulging discs, common in someone Lupe’s age, which could possibly be related to her back pain.

ScenariosLive_HealthesystemsGiven the lack of improvement in Lupe’s recovery and what he’s seen on the MRI, the occupational medicine specialist also writes a light duty work restriction for her.

The occupational medicine specialist also seeks authorization from the claims handler for Lupe to visit a spine surgery specialist.

“Another doctor? Why?” Lupe says after the claims handler authorizes that referral. Lupe’s anxiety over her course of treatment is beginning to ratchet up.

The conversation with her manager after her company sees the work restriction note does not — from Lupe’s perspective — go well.

“We don’t see light duty as an option,” the manager says to Lupe with the assistance of a bilingual case manager from the TPA who works onsite. “We want you to go off work until you get better,” she says.

“Just until you get better, Lupe,” the case handler says encouragingly, seeing the fear in Lupe’s eyes.

ScenariosLive_HealthesystemsLupe, her back killing her, gets on the bus for the ride home that late afternoon, fearing for her livelihood. She can’t keep back tears on the bus, thankful that no one else is sitting next to her on the bus to see her tear-streaked face.

Fourteen weeks after her injury, Lupe is in increasing pain and anxiety. The burning sensation in her groin and upper leg has extended to her knee and she’s getting tingling and numbness in her right toes.

The spine specialist reviews the MRI results and determines that one of the bulging discs in Lupe’s back is impinging on her sciatic nerve.

“We’re going to need to operate,” the spine specialist tells Lupe. In what is now a vain effort to manage her pain, her meds are upgraded to Lyrica, Oxycontin, IR and Flexeril.

Lupe is now convinced that not only her livelihood, but her very life is now in danger. But through an interpreter, she is mollified to the point where she submits to the surgery.

The Tragedy


Lupe undergos a discectomy, but 26 weeks after her injury, Lupe’s pain, anxiety and anger have only increased. The once dutiful, hard-working woman is a shadow of herself. Her use of painkillers has dulled her mind, to the point where most of her day is consumed watching television and eating take out.

Lupe’s inability to stick to a physical therapy regimen means that the operation offers her little relief or progress. Because of her ongoing pain, her spine specialist recommends spinal fusion, to be scheduled within two weeks. He also adds Ambien CR for sleep, Zofran to combat nausea and Provogil and Effexor to help her fatigue.

Where once Lupe had the energy to at least question the necessity for a medical procedure, now she has none. Lupe has also begun to put on weight. Where she weighed 142 pounds at the time of her injury, she now weighs 157 pounds.

More than six months after her injury, Lupe undergoes a spinal fusion operation with the idea that bracing her back in this manner can help her. Lupe is too weak to protest a visit to physical therapy, so she submits to four weeks of physical therapy after the spinal fusion procedure.

A coworker who lives in Lupe’s building comes to visit her one day. The normally clear-eyed Lupe’s face is puffy and her eyes are red.

“Lupe, what can I do for you?” her friend says.

“There is nothing you can do for me,” Lupe says. “The doctors don’t even know what they can do for me.”

ScenariosLive_HealthesystemsLupe’s friend looks down to the array of prescription medication bottles that Lupe keeps on the coffee table in front of her television set, next to cans of Mountain Dew and packages of Fig Newtons.

“Those medicines, I don’t even know the names of them,” Lupe’s friend says.

Lupe holds up a tattered spiral notebook, stained with coffee and pizza sauce.

“This is the only way I can keep track,” Lupe says. “I track them by color and shape. I take 20 pills a day, Magdalena, 20 pills a day.”

After four weeks of physical therapy post operation, Lupe is in as much pain as she ever was.

Her claims handler authorizes a return to see the spine specialist.

“Lupe, there’s really not much more I can do for you,” the spine specialist says.

Lupe returns to her occupational medicine specialist, who like the spine specialist, is at a loss as to what to do for Lupe. He increases the Oxycontin in an attempt to improve her pain management.

One look at her and the occupational medicine specialist knows that something else must also be done to relieve her pain. Her face is contorted with it.

Following the occupational medicine specialist’s recommendation, the claims handler authorizes Lupe’s visit to a pain specialist. The pain specialist reviews Lupe’s surgery and medication history and recommends surgery to implant a pain pump in Lupe, which the claims handler authorizes.

One day, Lupe’s claims handler comes to visit her, accompanied by a home health care aid who is there on her bi-weekly visit.

Like Lupe’s friend, the claims manager surveys the array of prescription bottles on Lupe’s coffee table.

“Lupe, we’ve got to do something to improve your quality of life,” the claims manager says.

“Improve my quality of life? This injury has ruined my quality of life,” Lupe says.

“I was better off taking aspirin and working than with this,” Lupe says angrily, waving her hand at the eight medication bottles on her coffee table.

“We want to get rid of these bottles,” the home health care aid says. “We want to give you a pain pump to help you manage your pain.”

ScenariosLive_Healthesystems“A pain pump? What is that like a bicycle pump?” Lupe says.

“No,” the case manager says. “It’s surgically implanted.”

“Surgery! More surgery!” Lupe exclaims.

Lupe picks up a television channel changer, and tries to ignore her claims manager and health care aid by turning on the television to a Spanish speaking program.

Lupe Valenzuela will eventually be declared permanently disabled and will never work again.

The Session

This scenario was originally presented at the 2013 National Workers’ Compensation and Disability Conference in Las Vegas.

As part of the discussion, panelists discussed key aspects presented in the scenario.

Panelists included Dan Reynolds, R&I editor-in-chief; Dr. Robert Goldberg, chief medical officer, Healthesystems; and Tracey Davanport, director, National Managed Care, Argonaut Insurance.

Insights from their discussion are highlighted below:




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

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.


Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.

R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.


We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?


Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.


Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now and where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.


More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

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