Adjuster X

Rear Ended

By: | January 25, 2016 • 2 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]

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.

Advertisement




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.

Advertisement




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.

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.

Advertisement




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.

Advertisement




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]