THE GOOD, THE BAD AND THE UGLY Case studies in Workers Compensation

1. THE GOOD, THE BAD AND THE UGLY Case studies in Workers Compensation Susan Diamanti Workers Compensation Director

2. THE GOOD GOOD CLAIM PRACTICES CAN PRODUCE POSITIVE RESULTS EVEN UNDER THE WORST CIRCUMSTANCES

3. Immediate Treatment 29YO Teacher who was on her way to her car when a student grabbed her and forced her to the ground with a knife. Employee was not physically hurt but was having significant psychiatric difficulties. The employer reported the claim immediately and reached out to the adjuster regarding an immediate referral to a therapist. The adjuster had difficulty locating a psychiatrist that would see the patient immediately and rather than delay treatment the adjuster agreed to let the employee choose one and reimburse her for the costs. The employee was able to see the doctor the following day. The employee was able to return to full duty less than 6 months after the incident. She continued with therapy through the trial of the student and until she found another job and moved on. There was no litigation on the part of the employee.

4. Case Management 42YO Instructional Lead who was putting away large canvas umbrellas during strong winds and one of the umbrellas got caught in the wind and struck him in the face. He sustained multiple face fractures. The employer reported the injury to the insurance company within minutes of the accident and the adjuster was able to assign a case manager. The case manager went directly to the hospital to assist the employee’s spouse and coordinate treatment. Over the course of the first two weeks following the injury the Case manager facilitated the employee’s transfer to a subsequent hospital, coordinated care between multiple specialist and provided support for his wife and children. The employee returned to work with restrictions less than two months after the accident. His claim is barely a year old and is nearing completion.

5. Terminated Case involves a custodian who sustained an admitted low back injury due to lifting while taking out the trash. He attended physical therapy and chiropractic treatment and was discharged as cured 4 months after the injury. 7 months after the injury he caught on video stealing. On the day that his employer advised him that he was being terminated, he reported that he was still in pain and required treatment related to the work injury. The employer advised the employee contact the adjuster on the case and let them know that he needed additional treatment. The adjuster advised the employee that they would be denying any additional treatment since he had been discharged as cured from the injury.

6. THE BAD Missing one or more step at the beginning can result in costly claims

7. I’m Fine. but wait, maybe not 45YO Teacher who was trying to close a classroom door, while a student was trying to keep it open. Employee reported the incident the day it occurred but told her supervisor she was fine. The supervisor did not report the incident to the proper person or the insurance carrier. Several days after the incident the employee attempted to seek treatment but was denied by the doctor’s office indicating that there was no claim on file with the insurance carrier. The employee hired an attorney. When the claim was filed by the attorney there were several additional body parts added to the injury.

8. Bad Hire 64YO Counselor who reported pain in her hands, wrists, elbows, shoulders, neck and back due to a non-ergonomic workstation. She filed her workers compensation through an attorney within the first six months of employment. During the deposition of the employee, it was learned that the employee had previously filed 7 different workers compensation claims with 7 different employers and she had not completed a full school year for over 9 years. While our employer was barred from asking the employee about prior illnesses and injuries at the time of hire, they should have recognized this employee’s erratic prior work history they could have likely avoided hiring this serial filer. This denied claim continues in litigation and the last demand by this unreasonable applicant was $1,000,000.00.

9. Employer Pays 43YO Executive Assistant who reported low back pain after moving some boxes in February 2010. Her employer paid for several visits to a chiropractor following the injury but did not report the injury to their carrier. In 2012 the employee reported that her low back was bothering her and requested additional treatment. She indicated that it was related to the 2010 injury and not a new injury. The employer reported the 2010 claim to the carrier in 2012. When the employee was referred to the doctor the MRI showed a herniated disc in her spine. Since the employer was aware of the injury in 2010 and never reported it, the injury had to be accepted even though there was no evidence that the herniation was a result of the original injury.

10. The Retreat Case involves a teacher who was attending a retreat and one evening while walking around the grounds, the employee fell into a ravine, landing on her head. The employee suffered a closed head brain injury and was hospitalized for several months. An attorney was retained to represent her on the workers compensation claim and she also hired a civil attorney and brought suit against the facility where the injury took place. The employee was unable to return to her usual and customary job and agreed to a voluntary resignation in exchange for a buyout of both the civil and the workers compensation claims. The employer was aware of the resignation and provided a copy of the paperwork, however, they failed to document her personnel file, never terminated her employment and eventually allowed her to work with self modification of her job functions . Several years later, the new administration at the employer found the resignation but it was too late, the employee was a tenured teacher and terminating her employment was extremely difficult and costly.

11. THE UGLY Sometimes there is nothing that can be done

12. Keep Your Eye On The Ball Case involves an Special Education teacher who was hit on the side of the head by a soccer ball kicked by a student. Employee sustained a concussion and has been off work for almost two years. While the actual injury was not severe, the incident caused a significant aggravation of a pre-existing condition. The employee hired an attorney to represent her related to the work injury. The employee was recently involved in a fender bender while on her way to treatment and has now hired a third party attorney related to that accident and the work attorney is amending her work comp claim to include back, legs, psych, etc.

13. Permanent damage 55YO Instructional Aide who fell down the stairs and broke her right wrist. Employer reported the injury immediately and the employee underwent surgery to repair her wrist with metal hardware. The hardware was removed after the fractures healed but the employee began to have significant pain and inability to use her hand. Through multiple treatments and multiple specialists it was determined that the employee’s condition would never improve and she had lost the essential use of that hand. The employee is considered to be permanently totally disabled and will receive full workers compensation benefits for the remainder of her life.

14. Factors that affect outcome

15. Factors Continued