We often see unusual occurrences and claims in the claimsmanagement world, including claims that take strange turns andtwists. Sometimes these twists and turns are comical, whileon other occasions they can be tragic. In some rare cases, theunfortunate occurrence of a work-related injury can lead todiscoveries that ultimately benefit the employee.

I recently read an article by a financial expert who was writingabout overcoming debt. For people who found themselves in debt, herecommended that they stop using their credit cards or “If you'rein a hole, quit digging.” That is, quit creating moredebt. While that is very sound advice in the financial world,in the claims world we often find ourselves in a hole, and it isalmost never wise to stop digging.

About 20 years ago a company received a workers' compensationclaim from an employee in a manufacturing plant who fell in thebathroom. He was in an authorized area and there was noquestion about the legitimacy of the claim, since several employeesheard him fall. They ran to his side quickly, and fortunately theinjury was minor. However, the unusual thing about the injurywas that the employee fell from atop the sink while inspecting hishemorrhoids in the mirror. I cannot think of one lesson that Ilearned from this incident, other than the fact that I can'tbelieve he reported the claim as accurately as he did. Also,I can't seem to get that picture out of my mind.

Now—– to more serious items.

Workers' compensation claims

Some of the most unusual claims arise out of work-relatedincidents, and sometimes an injury can have an unexpected andbeneficial outcome. Many years ago, an adjuster managed a workers'compensation claim in which an employee in a factory thatmanufactured seat belts rose up from a bent position and struck hislower back on the arm of a machine. Unfortunately he rose up veryquickly, causing a great deal of pain. He went to the first aidoffice, which in that large plant was staffed by a registerednurse.

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, hedid not respond to the conservative care as quickly as expected, sohe was sent to an orthopedist. During the course of theexaminations and follow-up, including an MRI and an independentmedical examination (IME), it was found that the employee hadcancer in his back. Obviously that was very tragic, but the factremains that this was found as the result of treatment for awork-related injury, and the employee was able to start cancertreatment quickly.

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

The benefits of this prompt attention were three-fold:

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

However, occurrences such as these do not always end sofavorably. I recently reviewed another claim in which cancer wasfound during the course of the employee's treatment for a backinjury, which included a back fracture. He was in acute pain, andbecause of the pain and the fact that he had no one at home to carefor him, he was placed in a rehabilitation facility. Unfortunatelyhe 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 tostay in the rehabilitation center was due to his legitimatework-related injury or due to his cancer, so finally an IME wasordered. At the same, time the adjuster and a nurse case managerstarted inquiring about the use of home health care to allow him tobe discharged from the rehabilitation center but still receive ahigh quality of care. This question had not been resolved at thetime of my last inquiry, but the employee had already been in therehabilitation center for over five months and the $10,000 permonth costs were continuing for the foreseeable future.

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

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

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

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

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

1. The adjuster identified that the employee's treatment plan wasnot working as expected,
2. The adjuster assigned the claim to a nurse case manager who hadsome additional expertise that was needed at a later date,
3. The prompt use of specialists and technology allowed them allto identify an underlying condition that was obviously causingmajor complications, and
4. A more favorable outcome was achieved.

You might also say that the injury or back condition describedin the first incident was less severe or the cancer was fartheralong than that described in the second incident, and obviouslythat could be part of the explanation and the difference inoutcomes. There are also clearly differences in how people respondto treatment, the pain that they feel as a result of injuries andillnesses, and their needs for different kinds of treatment. It isvital, however, for claims professionals to promptly investigatedeviations from the norm when managing claims and to spring intoaction when underlying conditions aggravate a work-related injury.Only then can you reasonably determine how best to care for theemployees and how to proceed with managing the claims for which youare responsible.

Gary Jennings, CPCU, ARM, ALCM, AIC, ARe, SCLA, is theprincipal consultant at Strategic ClaimsDirection LLC. He may be reachedat [email protected].