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]

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