Adjuster X

The Unexpected Detective

By: | April 7, 2014 • 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]

Ray Simpson, the claimant, reported two days previously that he picked up a box and felt immediate, severe pain in his back.


I drove over to meet with the plant manager and Simpson’s supervisor, who told me Simpson was about 6-foot-2, 220 pounds and very fit. I lifted one of the boxes Simpson had been unloading from a pallet and noted that it weighed about 25 or 30 pounds — not especially heavy, but still capable of causing an injury if it was lifted incorrectly.

Simpson was directed to the local ER for treatment, and later called his supervisor to see which doctor he should follow-up with.

I called Simpson at home, but there was no answer. So I called the doctor’s office, and they told me Simpson had an appointment that afternoon. When I called the doctor’s office again, the nurse told me the doctor diagnosed Simpson with lumbar strain and sprain. He recommended bed rest, pain medication and muscle relaxers, and authorized a week of lost time. The nurse noted that the doctor did not have objective findings to substantiate Simpson’s subjective complaints.

The next morning, I called Simpson’s house again, but there was no answer. In order to complete 24-hour contact, I had no choice but to go to his house unannounced. I wasn’t happy about it — Simpson lived in a neighborhood with a high crime rate.

On the steps of Simpson’s brownstone were several men who eyed me warily as I pulled up to the curb. I soon realized that my trench coat made them think I was a detective. I asked if any of the group knew Simpson.

“His apartment’s on the second floor. Don’t know if he’s in,” one of the men on the steps said.

As I made my way up, I wondered how well Simpson could climb those stairs with his bad back. There was no answer to my knock.

Back down on the steps, I asked again. One of the men said Simpson might be down at Ace’s Garage, which was two blocks away.

I parked there, and inside, I saw a group of men gathered around. One yelled, “The man’s here!” after which they scattered, leaving behind a pair of dice. I had inadvertently broken up a craps game.

On the way back to Simpson’s apartment, I saw a man fitting Simpson’s description approaching the building. I called out to him and he stopped, looked at me, and said, “Aw, come on, man. You’re not gonna bust me for gambling instead of all those other dudes who were in the game too.”


“Let’s go for a ride and talk about it,” I said.

As I drove, I told Simpson I was a claims adjuster investigating his comp case.

“I thought you were a cop!” he said.

I replied that it didn’t take a detective to notice that his ability to bolt from the craps game indicated he wasn’t in a lot of pain.

Simpson agreed.

“With the pills Doc gave me, and some rest, it got better. In fact I’m feeling really good, and I’m ready to go back to work.”

And he did the next day. The claim wound up involving no compensable lost time. As for me, I decided my trench coat was a valuable fashion accessory.

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.


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.


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]