Adjuster X

House of Cards

By: | November 2, 2015 • 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]

Gregorio Molina, a night watchman, was assaulted during a break-in and was left with an incomplete spinal cord injury. The perpetrator fled the state, wasn’t apprehended and there was no possibility of subrogation.


Litigation followed the incident, and Molina was awarded lifetime benefits. His wife was designated as his caregiver with a monthly stipend.

I got the case because my claims unit often received takeover claims from other administrators.

Of immediate concern was the claimant’s medical condition. His sedentary life and weight gain over the years resulted in high blood pressure, diabetes and elevated cholesterol.

He was also incontinent with frequent urinary tract and upper respiratory problems.

A significant problem was recurrent bedsores. Visits to the hospital were the norm.

There hadn’t been a nurse case manager assigned for years. Additionally, our state compensation act gives the claimant the right to choose their own providers.

I asked case manager Anne Spears to visit Mr. Molina. After reluctantly getting permission from his wife, Anne told me: “Their house is old and shabby, with a rickety wood deck off the second floor. Sanitary conditions were poor and the claimant sat silently in an old wheelchair.

“Mrs. Molina was guarded. Maybe that was due to her poor English. She said her husband’s day was spent on the second floor and sometimes out on the deck playing cards. I question whether she is giving him the proper care,” she said.

It was recommended Mrs. Molina attend special caregiver classes and allow bi-weekly case manager visits. Her attorney demanded cessation of case management, but when another urinary tract infection required an ER visit, I used the incident to reach out to the attorney. His belated response provided approval, but with caveats – such as bathroom renovations, an elevator and gym.

Excelsior Redesign was tasked to evaluate the house.

“You face major renovation costs with this house,” Mike Kinney told me.

“The roof is shot, leaking into the third floor and compromising the second-floor deck integrity, which is unsafe. The electrical system isn’t up to code, and cracked ceilings and walls throughout suggest damage to the floor joists and foundation.”

Including a $50,000 elevator, widened doors and a second floor emergency exit, Excelsior gave me an estimate of $485,000.

I met with my claims manager who suggested purchasing a newer single level house instead of paying for renovations. Mrs. Molina declined our offer but agreed to take classes.

For a time, all was well but then her attendance became spotty. I felt surveillance was needed.


The investigator called to tell me that Mrs. Molina makes frequent trips to Mexico, staying for weeks. During that period, a daughter would care for her father. We heard that she was planning to garner rental income from the restored second floor.

I wrote to the Molinas’ attorney advising him that the limited renovation was off the table.

Absent adherence, we informed the attorney that we would motion the court to have Mr. Molina admitted to a care facility, thus ending Mrs. Molina’s caregiver stipend.

Surprisingly a favorable answer was received. Compliance improved, case management was reinstated and a limited modification was completed.

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]