Adjuster X

It Happened at Work, or Not!

By: | August 4, 2014

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 claim on my desk involved a veteran worker, Joe Esker, a 51-year-old warehouse supervisor for Bascom Brothers. According to the report, he felt ill and had left arm pain on the morning of the incident. An ambulance was called and he was admitted to the hospital with a heart attack.

I began my investigation at Bascom. Connie, the HR manager, told me that she got a call at 8:30 a.m. saying that Joe was in distress. She called 9-1-1 and an ambulance arrived within 10 minutes.

I asked what Joe had been doing just prior to that and she said nothing unusual. Joe’s position, I learned, was largely administrative. His duties included scheduling workers, completing paperwork, and ensuring orders were filled correctly.

I spoke with Stan, the employee who had reported Joe’s distress. Stan said Joe arrived early and went straight to his office.

Joe was at his desk at 8:10 when Stan came in to discuss a shipment. Joe looked pale and mumbled a reply.

Stan asked if he should get help, but Joe wanted to see if it would pass. Stan came back a few minutes later, saw Joe grasping his left arm, and immediately called Connie.

I asked Connie why she submitted a workers’ comp report for Joe’s heart attack. She replied, “Because it happened at work.”

I arrived at Joe’s house later to take his statement. He readily admitted that the most physical thing he’d done that morning was get a cup of coffee.

I asked about the night before the incident. He said he was bowling. I asked how he’d felt at the time.

“To tell you the truth, I felt a bit nauseous, like I had severe heartburn,” he said.

“When I came home, I went straight to bed.”

Joe said he had no history of health issues.

Before I left, he asked, “Why the big investigation? This happened at work.”

I answered as best I could.

Joe signed a medical release, so I drove to the office of the cardiologist who’d treated Joe. The doctor hadn’t finished dictating his notes on the case yet, so I asked if a serial enzyme study had been done. The nurse said yes, but that the results wouldn’t be back for a day or two.

That was good news. Serial enzyme studies can help pinpoint the onset of a heart attack.

When the study came back, the results were as I had expected. I drove back to Bascom and told Connie that the claim wouldn’t be covered by workers’ comp.

She was stunned.

“It happened at work,” she protested.

I explained that in order to be compensable, an injury or condition must arise out of and in the course and scope of employment. There was no evidence Joe’s work brought on the heart attack. I told her the test indicated the heart attack most likely began while he was bowling.

We got Joe and his wife on the phone.

“The serial enzyme study indicates your heart attack really began when you were bowling,” I explained as we denied the claim.

“It simply continued to progress while you were at work.”

I explained that his claim could be submitted to his major medical carrier.

After the call, Connie fretted, “I hope he doesn’t call a lawyer.” I agreed, but assured her we had a solid defense.

“This certainly taught me something I didn’t know about workers’ compensation coverage,” Connie said.

“I think Joe feels the same,” I replied.

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