Adjuster X

Rear Ended

By: | January 25, 2016

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]

The cover letter on the loss report was curt and suggested that the claim be denied. The incident was a car accident involving a nurse case manager. Her vehicle slowed at an intersection and was rear-ended.

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I couldn’t reach the employee so I left a voice mail. The employer told me that at the time of the accident, their case manager, Eileen McCord, was enroute to see a client. Before that she’d been on a lengthy conference call from her car with another customer. When the call ended, she advised her manager she was running late for her next appointment.

McCord was admitted to the hospital with a concussion, cervical trauma, facial fractures, a fractured left arm and elevated glucose levels — she was diabetic. According to the employer, McCord was 54 years old, divorced, and had been employed there about two years. They said she was a good but not outstanding worker. They also noted that McCord wasn’t wearing her seatbelt at the time of the accident.

Return-to-work was looking less feasible and the treating doctor had placed restrictions on driving and prescribed antidepressants and pain medications.

My call with the broker was contentious — he demanded the claim be denied. Both he and the employer believed that since McCord wasn’t wearing her seatbelt, resulting in more severe injuries, she was negligent. I told him that my investigation was still ongoing and any decision now would be premature.

It took a few more days until I received the police report and it confirmed the seatbelt was not worn. The name of the other driver was obtained but my attempt to contact him was unsuccessful. There was no insurance on his vehicle.

I assigned a nurse case manager due to the severity of the injuries, the claimant’s age and history of diabetes. Reports from our case manager confirmed that the McCord had a concussion, fractured jaw, left wrist fracture, was periodically disoriented, had blurred vision and elevated glucose and had difficulty walking. A recorded statement would not be feasible at this point.

The claimant remained hospitalized six additional days and was transferred to a sub-acute facility. While there, she was not meeting her goals and the prognosis remained guarded. My case manager said she was having short-term memory problems. At that point, I received a representation letter from the claimant’s attorney demanding that we accept the case.

I spoke with my house counsel who felt the case was compensable. She noted that state law reduces benefits by 25 percent when seatbelts are not used. She didn’t see any viable basis for denial. She also felt that taking the reduction, though lawful, would result in unfavorable publicity.

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I accepted the case and benefits for indemnity and medical were paid. Our case manager continued to provide us with updates that were not encouraging due to continued neurological and vision problems.

Return-to-work was looking less feasible and the treating doctor had placed restrictions on driving and prescribed antidepressants and pain medications. A home health aide was requested and we agreed.

Ten months passed without much improvement. Opposing counsel claimed psych overlay and total disability. Independent medical exams were done. The claimant’s examiner found treatment was still required, noted depression, and felt existing restrictions precluded work.

Our examiner found the claimant reached maximum improvement and felt she could work if restrictions were lifted and hours limited. Further defense of the case would be time consuming and costly so reluctantly we accepted the case for lifetime disability.

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