Adjuster X

A Matter of Defense

By: | December 10, 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]

“We have a bad one over at Dietrich Parcel Delivery Service,” said my supervisor.

“Some kid got de-gloved by a conveyor belt. Get out there now.”

Mark Wilson, an 18-year-old, had got his right hand caught in a conveyor belt. “Ripped the flesh off of his index through his pinky finger. Ugly injury with blood everywhere,” said Keith, the director of risk management. Wilson was transported to the hospital and admitted. The injury was witnessed.


“Seems cut and dried to me,” I said.

Keith looked pained. “Well … he wasn’t exactly at work,” he said. “Mark resigned last week. He was here picking up his last paycheck.”

First things first — I needed to speak to the witness. Keith introduced me to Ron Miller, 19, an employee for more than a year. He and Wilson had worked together for several months.

Miller said Wilson approached him at 10:15 a.m. to chat after picking up his last paycheck. As they were speaking, Wilson casually placed his right hand on the edge of a stopped conveyor belt.

“If you deny the claim and he hires an attorney, any lawyer will tell him to file a liability action, which is far more lucrative.” — Adjuster X

There was a sign above the belt that read: “Do not place hands on or near conveyor belt.” The belt suddenly started moving and Miller immediately hit the “kill” switch but  Wilson’s hand had already been pulled into the power sprocket pulley. He was screaming and covered in blood.

My next stop was the hospital. Wilson was being stabilized. I was able to speak to the attending physician on the case. Wilson had lost most of the flesh on his four right fingers. The doctor estimated a 16 to 20 week disability period.

I was able to see Wilson the next morning for a statement. His account matched up with Miller’s. He explained that since everyone at the plant knew him, no one stopped him from walking through the plant, even though he no longer worked there.

Wilson’s parents were with him. His father asked what type of insurance would be covering the medical costs. I explained that I was working to determine that, and would advise them shortly.

I consulted defense counsel and then went back to speak with Keith. I explained that as Wilson was no longer an employee, he was not in the course and scope of employment at the time of the accident. As such, the claim could be denied under workers’ compensation. “However,” I cautioned, “he will probably be successful if he challenges the denial.”

Keith was astounded. I explained that when Wilson came to pick up his paycheck, which the company authorized, no one escorted him out. That allowed him to go see his friend.

“He can argue that picking up his paycheck was an act intrinsic to his job, because the paycheck would have not been disbursed if he had not worked here.

“Unfortunately,” I added, “the WC courts in this state have found compensability on far less.”

Keith was adamant. “I want this claim denied!”


I sighed. “You can do that. But you’ll be exposed under your liability cover, which is $5 million. He can mount a compelling argument that the company was negligent in not having safety guards around the conveyor belt.”

I gave that a moment to sink in. “If you deny the claim and he hires an attorney, any lawyer will tell him to file a liability action, which is far more lucrative.”

Keith ruminated for a moment. “We just can’t seem to win on this comp stuff,” he said.

“Think of it as the cost of protecting your liability cover,” I said. “Relax. It could have been worse.”

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]