Adjuster X

Fatal Excursion

By: | September 14, 2015

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]

On the first day after my vacation I received Lauretta Mooney’s dependency claim petition. Risk manager Brett Basile acknowledged knowing the decedent and shared information freely.

Advertisement




‘Work hard and play hard’ is often a mantra in commercial real estate sales. Lauretta’s husband, George, epitomized that philosophy. Perhaps it had to do with his hardscrabble Boston upbringing. A part-time job during college burnished his resumè and he landed an outstanding position with Globus Partners, a multinational commercial realty enterprise.

Twenty years with the same company may not be typical, but it was George’s anchor. He worked hard — constant trips including cocktails and dinners with potential customers. His sales skyrocketed and recognition followed. They bought a larger house and a boat.

Then, he won an incentive trip to Spain. That was where he died.

“After the funeral Lauretta appeared withdrawn,” Brett told me. “Their house is too large and mortgage payments are tough. Surprised George didn’t have a lot of life insurance.”

Our conversation focused on the nature of our workers’ compensation law. The statute was unequivocal in requiring that claims had to arise out of and in the course of employment.

“The trip was a result of work,” Brett said, “but it’s in the interpretation of the causal relation requirement that cases rise or fall.”

The burden of establishing causal relationship rested with Lauretta. We, of course, had the reverse burden. I requested copies of George’s award, trip itinerary, and the Spanish death certificate. We requested medical reports, a list of medications, and information on smoking and liquor use. We also subpoenaed his group health claims.

The goal was to present all of the information to a specialist in internist medicine for an opinion on a causal relationship.

We learned the decedent was overweight, smoked, drank, had high cholesterol and diabetes. Our internist opined that George, 52, wasn’t in good health and that his comorbidities put him at greater risk of death due to heart attack or stroke. The petitioner’s expert — no surprise — had a completely contrary finding.

I sat in on the pre-trial as Lauretta testified about the couple’s last day in Madrid.

Globus had arranged a tour to the Valley of the Fallen, a historic war memorial site covering 3,300 wooded and hilly acres.

Lauretta testified she phoned a Madrid friend to talk about the beautiful but rugged terrain.

“We were walking a lot and I felt like a mountain goat!” Adding to the challenge was the heat and humidity. George had to stop frequently to sip water and catch his breath, she said.

As they confronted another hilly incline, he collapsed. She yelled for help — George’s breathing was labored, but it was too late when rescuers arrived and attempted resuscitation.

Advertisement




Both sides testified to their medical opinions, and in chambers, the judge advised the attorneys he was ruling for the widow.

Back on the bench, the judge said, “Evidentiary facts are that the decedent worked for the employer in a demanding position, winning awards. The rigors of the Spanish trip are memorialized. There may have been pre-existing conditions, but statute stipulates employers take employees’ health as they find it. I approve lifetime compensation benefits in favor of the petitioner.”

More from Risk & Insurance

More from Risk & Insurance

Risk Matrix: Presented by Liberty Mutual Insurance

10 Risks Becoming More Severe Due to Climate Change

Climate change is generating powerful storms, excess flooding and billions in damages. These are the risks insurers need to keep an eye on as temperatures increase.
By: | September 3, 2019




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