Adjuster X

The Sixth Sense

By: | October 1, 2013 • 3 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 claim seemed average enough. A 37-year-old male employed by a factory claimed to have injured his right arm when picking up a 50-pound basket of tools. He said the arm was now numb and couldn’t be used. The injury appeared to be soft tissue in nature.

I thought it was perhaps an ulnar nerve issue.  Scott, the employee, had seen a doctor, who ordered him off work until further examinations could be completed. X-ray results were negative.

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I met the employee at his house. The way the injury occurred seemed straightforward enough, but something was off.

After the interview, I outlined what benefits he could expect to receive.

Next, I went to speak with Scott’s supervisor. He confirmed there had been no witnesses to the incident. Scott had come to him with his right arm “dangling” by his side, claiming he had picked up the basket and his arm went numb. He told Scott to go to the company-designated doctor.

I called the doctor’s nurse, who confirmed that the X-ray was negative for a fracture. However, Scott exhibited a very weak pulse and low blood pressure on the right arm, although the left arm readings were normal. The doctor ordered more tests.

The additional tests turned out to be negative. However, Scott continued to claim his right arm was numb. The doctor asked him to report back to the office. Upon examination, the pulse and blood pressure of Scott’s right arm were still very weak. Afterward, the doctor called me to say he was baffled, but suggested calling in a neurologist or vascular expert.

I had three days to make a determination of compensability. There was no way the additional evaluation was going to be made within that timeframe. It looked like I had no choice but to issue a check — but then I had an idea.

I asked the nurse to meet me at the plant and to bring a stethoscope and a blood pressure cuff. Next I called the plant and asked the foreman if it was okay to have Scott come in to discuss his case. I asked the foreman to attend the meeting.

I didn’t call Scott until 9:30 the next morning. I told him that I had my checkbook with me and would issue him a TTD check after he answered a few more questions. He complained about the short notice, but showed up.

I met Scott in the foreman’s office. I asked for the nurse, who was in the next room, She checked his blood pressure and pulse, and both were normal. There were no physical findings to substantiate Scott’s complaints.

Scott accused me of ambushing him. “Come on, Scott,” I replied. “You know what you did.” His face got red. I continued, “The symptoms you exhibited were self-induced, weren’t they? You probably tied a band or rubber hose around your upper right arm just before you saw the doctor each time.”

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Scott began yelling, “You can’t prove that! You aren’t a doctor!”

The foreman glared at Scott, “I expect you to be at work tomorrow at 7 a.m. You’re lucky I’m not firing you here and now.”

Scott stormed out of the office. The foreman and nurse both looked at me and said, “How did you know?” I said, “Adjuster’s sixth sense. Something about the symptoms led me to think they might be self-inflicted.”

They both shook their heads as I left the office.

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.

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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.

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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]