Risk Scenario

Mr. Jones

A once fit, hardworking man in his sixties gets hurt and his case goes into an unexpected tailspin. Will Ben ever return to work?
By: | August 1, 2013 • 6 min read
Risk Scenarios are created by Risk & Insurance editors along with leading industry partners. The hypothetical, yet realistic stories, showcase emerging risks that can result in significant losses if not properly addressed.

Disclaimer: The events depicted in this scenario are fictitious. Any similarity to any corporation or person, living or dead, is merely coincidental.

Part One

Ben Jones could see at a glance that his younger colleague in the lumber department at the House and Home Mart in San Rafael was in a jam.

Scenario_MrJones

Sonny was standing with a married couple in front of rows of deck sealant. Ben could tell that Sonny had no idea how to answer a question that had just been posed to him.

“Anything I can help you with?” Ben said as he ambled up to the trio.

“Uh … yeah,” Sonny began to say when the man of the house cut him off.

“We’re just trying to decide on the best deck sealant here,” the man said. “Our deck is about seven years old and I’d like to not have to replace it anytime soon.”

Ben could see that the husband was impatient with Sonny’s lack of knowledge.

“Well, let’s see…” Ben said and he bent to look at the sealant that was on display.

“If it were my deck…” the retired lead carpenter began with an air of confidence; and he heard Sonny exhale with relief as he took over.

The customers accepted Ben’s recommendation, put five gallons of sealant in their shopping cart and went on their way.

“Thanks Ben, again,” Sonny said.

They both laughed. Sonny was no expert on home renovations. With 30 years’ experience in the industry, Ben was glad to help the younger worker.

Ben mused as he walked away from Sonny.

“Well, you just never know how things are going to turn out,” he thought.

Ben was the envy of his buddies. He was fit and prided himself on top-notch workmanship.

Scenario Partner

Scenario Partner

Making good money as a lead carpenter on homes in Sonoma, Marin and Napa counties, Ben had salted enough away to buy a nice fishing boat that he used to take his friends on fishing trips out to the Farallon Islands.

But Ben had seen his retirement nest egg pinched by the recession. So he took this job to make sure he didn’t miss his payments on his boat or home equity loan.

It was a good deal for a retiree. The company gave him a decent hourly wage and benefits.

All he had to do was work this job for a year or two and he could return to full retirement.

It was another worker, this time a young laborer for a local contractor, who wrecked that plan in an instant.

Ben had left the paint and varnish aisle and was turning to go get a drink of water when the young laborer, who was texting as he pushed a cartload of 12 foot two-by-fours, ran the cart right into Ben’s back.

The momentum and weight of the cart knocked Ben to the ground and he screamed from the pain of the blow. Ben knew immediately that he was hurt badly.

The younger man rushed to help Ben up. But Ben, angry at the younger worker and feeling great pain in his lower back, waved him off.

Ben wasn’t even sure if he should be moved.

Part Two

Sarah Fuller, the adjustor on Ben’s case, had more than 15 years’ experience in claims management.

Scenario_MrJonesShe had been around enough to know that although there were commonalities in the best practices of treating injured workers, each case was unique. The challenge was in identifying the nuances in each case.

Sarah thought that Ben’s case had all the earmarks for a positive outcome. He was fit, known as a hard worker and had no recorded history of anxiety or depression.

His back injury was serious, though, suffering blunt force trauma to his lower back like he had.

Sarah figured Ben could be back at work in three months. All his records indicated that Ben had the right attitude.

Sarah had authorized a physical therapy regimen requested by Ben’s doctor with the idea that he could at least work at the customer service desk part-time as a way of transitioning back into full-time employment. She made a note to check his file again in 30 days.

***

Ben stood up from the couch and grimaced as pain shot through his lower back. The sharp knife of pain caused him to gasp and reach out his right hand to the arm of the couch to steady himself.




“Dang it!” Ben said.

Ben had never hurt this bad or taken so long to come back from an injury. Angrily, he took a swipe at the half-eaten bag of potato chips on the couch.

Ben looked down and could no longer see his belt. He had a gut for the first time in his life.

From the couch, Ben moved slowly to his dining room table. He needed to sit but he didn’t want to sit. At that table was a pile of bills that he couldn’t bring himself to look at.

Ben made his way to the bathroom.

Looking at his bulging stomach in the mirror, Ben gave it an absent-minded pat. Never mind, today was his doctor’s appointment.

“I’m sure he’ll have plenty to say about this,” Ben said.

“Better get going.”

Ben had never had much use for painkillers, but he popped one in his mouth on the way out of the bathroom.

***

In the doctor’s office, Ben’s belly and money problems weren’t the only point of focus.

“I’ve got the results of your blood test,” the doctor said.

Ben just waited. The doctor’s expression told him it wasn’t good.

“Your total cholesterol is at 255 and we don’t like that,” the doctor said. Ben and the doctor also discussed the stress from Ben’s recurring financial problems.

Ben left the doctor’s office with prescriptions for Effexor, an anti-anxiety medication and Lipitor, a statin that helps to control cholesterol levels.

Maybe it was Ben’s bad back. Maybe it was the combination of back pain, weight gain and the effects of the statin. But two weeks after his doctor visit, Ben felt as if he was in even worse shape.

Ben had developed pain and weakness in his shoulders and hips, to go along with his compromised lower back.

And his weight continued to rise. In just two weeks, his weight shot up another eight pounds to 201, 26 pounds over his pre-injury weight.

“You’re 60,” his doctor told him on a return visit. “You’ve got to modify your diet or you’re going to dig yourself a hole you can’t get out of.”

“But the thing is, Doctor Stevens, I don’t eat a lot of fried food, or red meat even, I don’t know what’s going on here. I just need to get moving again,” Ben said.

Back at home, Ben got a call from one of his fishing buddies.

“Hey Ben, it’s Carl, when we heading out to the Farallons again?”

“I don’t know Carl, I’m not feeling so hot these days. My back is killing me.”

“Hang in there buddy, we’re all pulling for you,” Carl said.

“Thanks Carl, just don’t go catching any 40-pound salmon without me.”

Carl giggled when Ben said that. But after he hung up the phone, Carl felt a pang of worry.

Ben just didn’t sound the same.

Part Three

Sarah was in a breakout session at the RIMS conference in Hawaii when it hit her.

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The session was on factors that can undermine the management of workers’ compensation claims.

“Age,” the presenter had just written the word on the wipe board and underlined it.

“Weight,” the presenter wrote, underlined and articulated again.

“There are others, but these are two factors that can sneak up on a claim, adding challenges you might not have thought were there,” the presenter said.

As she sat in the presentation, Sarah could see Ben Jones’ face in front of her as clear as day from the photo on his case file. In the photo he was grinning, but why was his case stretching on into the six and seven month range, she wondered?

Sarah was jarred by the associations from the session. When she got back to the office, she took a fresh look at Ben’s case and was surprised by what she saw.

Ben’s list of medications was growing and the frequency with which he was getting refills had increased. In addition to a pain killer, the Effexor and the Lipitor, Ben was now on a beta-blocker for high blood pressure. Were all of these claim-related, she asked herself.

In addition, there was no indication he had attended the physical therapy sessions she had approved.

After finishing a thorough review of Ben’s case, Sarah reached out to Ben to see what she can do.

“Ben, it’s Sarah Fuller, the claims adjuster on your workers’ compensation case.”

“Hi Sarah,” Ben says when he answers the phone. Instead of the strong voice of the vibrant outdoorsmen she knew Ben to be, his voice is cracked and weak.

“How is everything with you Ben?” Sarah says. “You don’t sound like you’re doing too well.”

“Well, I’m trying Sarah but I just can’t seem to get out of this funk,” Ben says. “I don’t know what exactly is the matter with me, to be honest with you.”

“How’s your back?” Sarah says.

“It hurts,” is Ben’s weak-voiced response.

Alarms went off in Sarah. Something needed to be done here and quickly.

“Ben, I’d like to send a nurse case manager out to see you,” Sarah says.

“We want to get you better and back to work sooner rather than later.”

Ben was receptive.

“You know that’s what I want,” he said.

“That’s what we want too, Ben,” Sarah said.

After hanging up with Ben, Sarah poured herself a fresh cup of coffee and squared herself firmly in her chair.

This case had gone off the rails a little, but with the help of a few clinical experts, it was now time to get it back on track.

Summary

A fit, hardworking man in his sixties goes into a tailspin after getting hurt on the job. Given the underlying factors his case was a candidate for closer scrutiny. Had medication approvals been given a closer look or had clinical or analytical resources offered by the PBM been applied sooner, perhaps his hard road back to work could have been made easier.

1. Don’t ignore the age factor: Despite the best intentions of the injured worker, age can influence the outcome of a workers’ compensation claim. As they age, injured workers may recover more slowly. Pre-existing, age-related conditions may require a number of therapies, including physical therapy and possibly medication. Review prior authorization requests carefully and if you have questions about a particular treatment, reach out to the physician or the clinical services team for the integrated care specialists that you use.

2. It’s a new economy: Cases like Ben Jones’ are becoming more common. The combination of an individual’s savings rate and cost of living increases, as well as other economic and social factors, is causing many workers to delay retirement or work in a second career. Stress from financial worries combined with a workers’ compensation injury can lead to insomnia and depression, which are known to exacerbate pain. Proactive claims management can help reduce, if not eliminate, these factors from influencing recovery.

3. Engage first: It’s human nature for some to not reach out when they sense that they’re in trouble. An aging worker might suffer in silence for months before reaching out for help. In managing a case like this, assume that you will be the one to say something first.

4. Weight can be a concern: In addition to age, weight can be a significant influence on the outcome of an injury claim. A significant amount of weight gain could be a side effect from the medication therapy regimen or sign of complications that, left untreated, could impede recovery and delay return to work. Ask questions about the medications being prescribed. Review medical and pharmacy records carefully.

5. Don’t overlook the value of specialists: Network connectivity, durable medical equipment and physician utilization review, medication plans, analytics, clinical programs, educational resources and communication portals – specialists offers a host of information, tools and support that when applied to a claim can make a positive impact.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at [email protected]

More from Risk & Insurance

More from Risk & Insurance

Exclusive | Hank Greenberg on China Trade, Starr’s Rapid Growth and 100th, Spitzer, Schneiderman and More

In a robust and frank conversation, the insurance legend provides unique insights into global trade, his past battles and what the future holds for the industry and his company.
By: | October 12, 2018 • 12 min read

In 1960, Maurice “Hank” Greenberg was hired as a vice president of C.V. Starr & Co. At age 35, he had already accomplished a great deal.

He served his country as part of the Allied Forces that stormed the beaches at Normandy and liberated the Nazi death camps. He fought again during the Korean War, earning a Bronze Star. He held a law degree from New York Law School.

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Now he was ready to make his mark on the business world.

Even C.V. Starr himself — who hired Mr. Greenberg and later hand-picked him as the successor to the company he founded in Shanghai in 1919 — could not have imagined what a mark it would be.

Mr. Greenberg began to build AIG as a Starr subsidiary, then in 1969, he took it public. The company would, at its peak, achieve a market cap of some $180 billion and cement its place as the largest insurance and financial services company in history.

This month, Mr. Greenberg travels to China to celebrate the 100th anniversary of C.V. Starr & Co. That visit occurs at a prickly time in U.S.-Sino relations, as the Trump administration levies tariffs on hundreds of billions of dollars in Chinese goods and China retaliates.

In September, Risk & Insurance® sat down with Mr. Greenberg in his Park Avenue office to hear his thoughts on the centennial of C.V. Starr, the dynamics of U.S. trade relationships with China and the future of the U.S. insurance industry as it faces the challenges of technology development and talent recruitment and retention, among many others. What follows is an edited transcript of that discussion.


R&I: One hundred years is quite an impressive milestone for any company. Celebrating the anniversary in China signifies the importance and longevity of that relationship. Can you tell us more about C.V. Starr’s history with China?

Hank Greenberg: We have a long history in China. I first went there in 1975. There was little there, but I had business throughout Asia, and I stopped there all the time. I’d stop there a couple of times a year and build relationships.

When I first started visiting China, there was only one state-owned insurance company there, PICC (the People’s Insurance Company of China); it was tiny at the time. We helped them to grow.

I also received the first foreign life insurance license in China, for AIA (The American International Assurance Co.). To date, there has been no other foreign life insurance company in China. It took me 20 years of hard work to get that license.

We also introduced an agency system in China. They had none. Their life company employees would get a salary whether they sold something or not. With the agency system of course you get paid a commission if you sell something. Once that agency system was installed, it went on to create more than a million jobs.

R&I: So Starr’s success has meant success for the Chinese insurance industry as well.

Hank Greenberg: That’s partly why we’re going to be celebrating that anniversary there next month. That celebration will occur alongside that of IBLAC (International Business Leaders’ Advisory Council), an international business advisory group that was put together when Zhu Rongji was the mayor of Shanghai [Zhu is since retired from public life]. He asked me to start that to attract foreign companies to invest in Shanghai.

“It turns out that it is harder [for China] to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

Shanghai and China in general were just coming out of the doldrums then; there was a lack of foreign investment. Zhu asked me to chair IBLAC and to help get it started, which I did. I served as chairman of that group for a couple of terms. I am still a part of that board, and it will be celebrating its 30th anniversary along with our 100th anniversary.

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We have a good relationship with China, and we’re candid as you can tell from the op-ed I published in the Wall Street Journal. I’m told that my op-ed was received quite well in China, by both Chinese companies and foreign companies doing business there.

On August 29, Mr. Greenberg published an opinion piece in the WSJ reminding Chinese leaders of the productive history of U.S.-Sino relations and suggesting that Chinese leaders take pragmatic steps to ease trade tensions with the U.S.

R&I: What’s your outlook on current trade relations between the U.S. and China?

Hank Greenberg: As to the current environment, when you are in negotiations, every leader negotiates differently.

President Trump is negotiating based on his well-known approach. What’s different now is that President Xi (Jinping, General Secretary of the Communist Party of China) made himself the emperor. All the past presidents in China before the revolution had two terms. He’s there for life, which makes things much more difficult.

R&I: Sure does. You’ve got a one- or two-term president talking to somebody who can wait it out. It’s definitely unique.

Hank Greenberg: So, clearly a lot of change is going on in China. Some of it is good. But as I said in the op-ed, China needs to be treated like the second largest economy in the world, which it is. And it will be the number one economy in the world in not too many years. That means that you can’t use the same terms of trade that you did 25 or 30 years ago.

They want to have access to our market and other markets. Fine, but you have to have reciprocity, and they have not been very good at that.

R&I: What stands in the way of that happening?

Hank Greenberg: I think there are several substantial challenges. One, their structure makes it very difficult. They have a senior official, a regulator, who runs a division within the government for insurance. He keeps that job as long as he does what leadership wants him to do. He may not be sure what they want him to do.

For example, the president made a speech many months ago saying they are going to open up banking, insurance and a couple of additional sectors to foreign investment; nothing happened.

The reason was that the head of that division got changed. A new administrator came in who was not sure what the president wanted so he did nothing. Time went on and the international community said, “Wait a minute, you promised that you were going to do that and you didn’t do that.”

So the structure is such that it is very difficult. China can’t react as fast as it should. That will change, but it is going to take time.

R&I: That’s interesting, because during the financial crisis in 2008 there was talk that China, given their more centralized authority, could react more quickly, not less quickly.

Hank Greenberg: It turns out that it is harder to change, because they have one leader. My guess is that we’ll work it out sooner or later. Trump and Xi have to meet. That will result in some agreement that will get to them and they will have to finish the rest of the negotiations. I believe that will happen.

R&I: Obviously, you have a very unique perspective and experience in China. For American companies coming to China, what are some of the current challenges?

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Hank Greenberg: Well, they very much want to do business in China. That’s due to the sheer size of the country, at 1.4 billion people. It’s a very big market and not just for insurance companies. It’s a whole range of companies that would like to have access to China as easily as Chinese companies have access to the United States. As I said previously, that has to be resolved.

It’s not going to be easy, because China has a history of not being treated well by other countries. The U.S. has been pretty good in that way. We haven’t taken advantage of China.

R&I: Your op-ed was very enlightening on that topic.

Hank Greenberg: President Xi wants to rebuild the “middle kingdom,” to what China was, a great country. Part of that was his takeover of the South China Sea rock islands during the Obama Administration; we did nothing. It’s a little late now to try and do something. They promised they would never militarize those islands. Then they did. That’s a real problem in Southern Asia. The other countries in that region are not happy about that.

R&I: One thing that has differentiated your company is that it is not a public company, and it is not a mutual company. We think you’re the only large insurance company with that structure at that scale. What advantages does that give you?

Hank Greenberg: Two things. First of all, we’re more than an insurance company. We have the traditional investment unit with the insurance company. Then we have a separate investment unit that we started, which is very successful. So we have a source of income that is diverse. We don’t have to underwrite business that is going to lose a lot of money. Not knowingly anyway.

R&I: And that’s because you are a private company?

Hank Greenberg: Yes. We attract a different type of person in a private company.

R&I: Do you think that enables you to react more quickly?

Hank Greenberg: Absolutely. When we left AIG there were three of us. Myself, Howie Smith and Ed Matthews. Howie used to run the internal financials and Ed Matthews was the investment guy coming out of Morgan Stanley when I was putting AIG together. We started with three people and now we have 3,500 and growing.

“I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.” — Maurice “Hank” Greenberg, chairman and CEO, C.V. Starr & Co. Inc.

R&I:  You being forced to leave AIG in 2005 really was an injustice, by the way. AIG wouldn’t have been in the position it was in 2008 if you had still been there.

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Hank Greenberg: Absolutely not. We had all the right things in place. We met with the financial services division once a day every day to make sure they stuck to what they were supposed to do. Even Hank Paulson, the Secretary of Treasury, sat on the stand during my trial and said that if I’d been at the company, it would not have imploded the way it did.

R&I: And that fateful decision the AIG board made really affected the course of the country.

Hank Greenberg: So many people lost all of their net worth. The new management was taking on billions of dollars’ worth of risk with no collateral. They had decimated the internal risk management controls. And the government takeover of the company when the financial crisis blew up was grossly unfair.

From the time it went public, AIG’s value had increased from $300 million to $180 billion. Thanks to Eliot Spitzer, it’s now worth a fraction of that. His was a gross misuse of the Martin Act. It gives the Attorney General the power to investigate without probable cause and bring fraud charges without having to prove intent. Only in New York does the law grant the AG that much power.

R&I: It’s especially frustrating when you consider the quality of his own character, and the scandal he was involved in.

In early 2008, Spitzer was caught on a federal wiretap arranging a meeting with a prostitute at a Washington Hotel and resigned shortly thereafter.

Hank Greenberg: Yes. And it’s been successive. Look at Eric Schneiderman. He resigned earlier this year when it came out that he had abused several women. And this was after he came out so strongly against other men accused of the same thing. To me it demonstrates hypocrisy and abuse of power.

Schneiderman followed in Spitzer’s footsteps in leveraging the Martin Act against numerous corporations to generate multi-billion dollar settlements.

R&I: Starr, however, continues to thrive. You said you’re at 3,500 people and still growing. As you continue to expand, how do you deal with the challenge of attracting talent?

Hank Greenberg: We did something last week.

On September 16th, St. John’s University announced the largest gift in its 148-year history. The Starr Foundation donated $15 million to the school, establishing the Maurice R. Greenberg Leadership Initiative at St. John’s School of Risk Management, Insurance and Actuarial Science.

Hank Greenberg: We have recruited from St. John’s for many, many years. These are young people who want to be in the insurance industry. They don’t get into it by accident. They study to become proficient in this and we have recruited some very qualified individuals from that school. But we also recruit from many other universities. On the investment side, outside of the insurance industry, we also recruit from Wall Street.

R&I: We’re very interested in how you and other leaders in this industry view technology and how they’re going to use it.

Hank Greenberg: I think technology can play a role in reducing operating expenses. In the last 70 years, you have seen the expense ratio of the industry rise, and I’m not sure the industry can afford a 35 percent expense ratio. But while technology can help, some additional fundamental changes will also be required.

R&I: So as the pre-eminent leader of the insurance industry, what do you see in terms of where insurance is now an where it’s going?

Hank Greenberg: The country and the world will always need insurance. That doesn’t mean that what we have today is what we’re going to have 25 years from now.

How quickly the change comes and how far it will go will depend on individual companies and individual countries. Some will be more brave than others. But change will take place, there is no doubt about it.

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More will go on in space, there is no question about that. We’re involved in it right now as an insurance company, and it will get broader.

One of the things you have to worry about is it’s now a nuclear world. It’s a more dangerous world. And again, we have to find some way to deal with that.

So, change is inevitable. You need people who can deal with change.

R&I:  Is there anything else, Mr. Greenberg, you want to comment on?

Hank Greenberg: I think I’ve covered it. &

The R&I Editorial Team can be reached at [email protected]