Workers' compensation claims

Some of the most unusual claims arise out of work-related incidents, and sometimes an injury can have an unexpected and beneficial outcome. Many years ago, an adjuster managed a workers' compensation claim in which an employee in a factory that manufactured seat belts rose up from a bent position and struck his lower back on the arm of a machine. Unfortunately he rose up very quickly, causing a great deal of pain. He went to the first aid office, which in that large plant was staffed by a registered nurse.

He was then sent to one of the physicians on the medical panel, which began a strange turn of events.

The initial diagnosis was that of a muscle strain. However, he did not respond to the conservative care as quickly as expected, so he was sent to an orthopedist. During the course of the examinations and follow-up, including an MRI and an independent medical examination (IME), it was found that the employee had cancer in his back. Obviously that was very tragic, but the fact remains that this was found as the result of treatment for a work-related injury, and the employee was able to start cancer treatment quickly.

The adjuster had assigned this claim to an in-house nurse case manager because this back injury had not been resolving as expected. Upon learning of the cancer diagnosis, the adjuster and nurse case manager agreed that they needed to quickly separate the treatment and disability for the back injury from the employee's treatment and disability for the cancer. Through the help of the orthopedist, the oncologist who was brought in to treat the employee's cancerous condition, and the insurer's medical advisor, they were able to isolate, as best as possible, the impact of each condition.

The benefits of this prompt attention were three-fold:

1. The treatment for the cancerous condition started in earnest and it was recognized as being the largest contributor to the employee's pain, treatment and disability,
2. The workers' compensation claim (and its related cost) was limited much more than it would have been if the adjuster and nurse case manager had not acted quickly to isolate the symptoms, and
3. The employee's cancer was in remission when the adjuster last inquired as a result of early identification and treatment.

However, occurrences such as these do not always end so favorably. I recently reviewed another claim in which cancer was found during the course of the employee's treatment for a back injury, which included a back fracture. He was in acute pain, and because of the pain and the fact that he had no one at home to care for him, he was placed in a rehabilitation facility. Unfortunately he remained there for several months at the cost of approximately $10,000 per month.

There was the ongoing question whether his pain and the need to stay in the rehabilitation center was due to his legitimate work-related injury or due to his cancer, so finally an IME was ordered. At the same, time the adjuster and a nurse case manager started inquiring about the use of home health care to allow him to be discharged from the rehabilitation center but still receive a high quality of care. This question had not been resolved at the time of my last inquiry, but the employee had already been in the rehabilitation center for over five months and the $10,000 per month costs were continuing for the foreseeable future.

How could we have changed the outcome of this claim? We won't have the final answer, because we do not yet know the outcome. However, we do know that the adjuster and the nurse case manager should have:

• Started earlier to order more in-depth tests, including the IME, to try to separate the work-related injury treatment and rehabilitee need from that of the cancer, and
• Started much earlier working on an alternative to get him out of the rehabilitation center.

It is difficult to know the extent of savings that might have been realized, but it is clear that significant savings, at least in terms of ongoing monthly rehabilitation costs, could have been realized with earlier actions.

So, the lesson learned from comparing these two somewhat similar claims and the moral of the story is “If you're in a hole, keep diggin'.” Workers' compensation claims rarely turn out better if left alone.

The first claim came to a better result for several reasons:

1. The adjuster identified that the employee's treatment plan was not working as expected,
2. The adjuster assigned the claim to a nurse case manager who had some additional expertise that was needed at a later date,
3. The prompt use of specialists and technology allowed them all to identify an underlying condition that was obviously causing major complications, and
4. A more favorable outcome was achieved.

You might also say that the injury or back condition described in the first incident was less severe or the cancer was farther along than that described in the second incident, and obviously that could be part of the explanation and the difference in outcomes. There are also clearly differences in how people respond to treatment, the pain that they feel as a result of injuries and illnesses, and their needs for different kinds of treatment. It is vital, however, for claims professionals to promptly investigate deviations from the norm when managing claims and to spring into action when underlying conditions aggravate a work-related injury. Only then can you reasonably determine how best to care for the employees and how to proceed with managing the claims for which you are responsible.

Gary Jennings, CPCU, ARM, ALCM, AIC, ARe, SCLA, is the principal consultant at Strategic Claims Direction LLC. He may be reached at [email protected].