Adjuster X

Through the Gap

By: | September 2, 2014 • 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]

A caller reported a serious workers’ comp injury involving a 44-year-old truck driver, Phil Howard. Initial facts were sparse. What we knew was that Howard was driving a truck in familiar territory when the truck inexplicably careened down a steep embankment.

Howard suffered multiple fractures and severe head trauma requiring hospitalization. The employer, a regional trucking line, was self insured for $350,000. My carrier had the remaining coverage.


Phil was married with two children and had worked at the company for 15 months. The employer described his performance as “adequate” and left it at that. There were no prior workers’ comp claims.

The accident investigation was ongoing. I explained that I would need to know if there were any state or national OSHA investigations planned but the employer remained circumspect.

A case manager had been to the hospital to visit with Phil and his family. Unfortunately, he was in a medically induced coma and the family was too distraught to speak.

The case manager confirmed blunt head trauma, opining it would result in cognitive damage. She didn’t yet know the extent of his other injuries.

No details about the truck were available, but to my way of thinking, examining the truck for steering or braking mechanism defects would be a good place to start, to determine if subrogation potential existed.

The employer hadn’t responded to our specialist’s request to examine the truck. I had 21 days to make a decision on compensability. The police report was still pending.

I called the claimant’s attorney and requested permission for continued case management — he agreed. He said he didn’t yet have subrogation information but he was open to protecting our subrogation interests.

I called the underwriter and advised on the truck inspection stalemate. Within four days, the truck was evaluated with a finding of no observed defects.

The police report yielded a perplexing surprise. The truck had left the interstate and traveled behind barriers on a portion undergoing reconstruction before plummeting 15 feet. There was a gap where a new bridge was planned. I spoke with the insured and advised that Phil’s unexplained actions raised serious compensability questions. Defense counsel concurred and planned to deny the case.

Eventually, Phil regained consciousness but had challenges with cognition, speech and vision. He was transferred to a post-acute rehabilitation facility.


As we prepared our defense, we decided to obtain the group health claims records. We also informally canvassed co-workers. They described Phil as moody and rumored to have an unhappy marriage. Group claims records reflected three hospitalizations for major depression/suicide threats.

An accident re-creation analysis concluded it was “highly probable” this was an intentional act. It noted the presence of warning signs and barriers, and the fact that it happened in broad daylight.

Despite a sympathy factor, we remained confident that we could successfully defend the case, but Phil’s inability to speak didn’t help either party. The judge recommended settlement considering Phil’s total disability. Ultimately, we reached a compromise paying only 30 percent of indemnity and medical, net of the self-insured retention.

Accidental or intentional? You decide.

More from Risk & Insurance

More from Risk & Insurance

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.


That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.


Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]