Adjuster X

House of Cards

By: | November 2, 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]

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.

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