Adjuster X

A Snow Job

By: | June 2, 2014

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]

As work-related injuries go, back claims are fairly ubiquitous. So it was no surprise to me that there was another batch with my new loss reports. One of them contained an employer’s letter, disputing a claim and requesting a thorough investigation. I complied and attempted to make phone contact with Liz, the employee.

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When the claim came up on diary, I still hadn’t heard back from Liz. I contacted the employer, and the supervisor told me that Liz, 48, was hired nine months prior as a stock room clerk. Her duties included unpacking merchandise — typically clothing, bathroom/bedroom furnishings and small appliances — and placing them on stockroom shelves. The employer mentioned that Liz had often been late and was given three verbal warnings. A fourth would result in termination.

Liz’s accident occurred on a Monday and was unwitnessed. She alleged low back strain while shifting boxes and unloading microwaves, toasters and bulky quilts. On Tuesday, Liz worked half a day and told her supervisor that she felt unwell and wanted to go home. Liz remained out until Thursday.

When she returned, she told her supervisor about the back injury, admitting she hadn’t brought it up at the time of occurrence. She said she thought it would get better on its own. She produced a note from her doctor indicating he was treating her for a low back injury. The note said Liz could only work if there was no bending, squatting or lifting. Since that was not feasible, the supervisor sent her home with a disability claim form.

When I hadn’t received any progress report from Liz’s doctor, I made several attempts to call Liz, but failed to reach her. A week later the employer called to tell me they received a denial from the disability carrier citing the industrial nature of the injury. I sent a final claimant contact letter. Ten days later, I received an attorney representation letter.

Around the same time, I received a report indicating that Liz had a prior back injury from falling on a train platform the previous year, with a diagnosis of herniated disc. The report noted there had been a compromise settlement. I called the treating physician’s office requesting an update. All they would advise was that Liz couldn’t work and remained under care. An independent medical exam was scheduled five weeks out so it didn’t seem there was much I could do at that point but wait.

A huge snowstorm the next day closed our office. Interestingly enough, I happened to pass through the town where Liz lived so I drove down her street. Quite a surprise awaited me as I saw Liz outside — shoveling snow in her driveway.

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I called the attorney and he recommended immediate surveillance. Within three days, we had film of Liz cleaning up snow, though not as actively as I had initially observed. In the meantime we received a report from Liz’s doctor stating that Liz remained disabled and needed surgery. Curiously, the independent medical exam found her employable, not requiring treatment, and with no residual disability.

Initial settlement efforts were futile. We got a hearing scheduled for three months out. A pre-trial settlement attempt also failed but we hadn’t played our trump card yet. At the hearing, defense counsel showed the surveillance video to the arbitrator and opposing counsel. Liz’s attorney reluctantly agreed to withdraw the claim. The arbitrator dismissed the case with prejudice, neatly closing the case of Liz and the snow job.

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