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On-Demand Webinar

Webinar: Improving Claims Outcomes Through More Effective Adjuster Management

Learn how to help adjusters achieve good results for payers and workers’ compensation claimants.
By: | April 16, 2014 • 1 min read

Presenters

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Overview

Claims organizations need to solve a number of problems that are impeding adjusters from achieving good results for both payers and workers’ compensation claimants.

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Webinar Sponsor

Due to changing regulations, provider consolidation and more – adjusters are overwhelmed and the bottom line is suffering as a result. Too many claims adjusters are so harried and distracted by their workloads that they are not efficiently performing the vital functions of closing claims, getting workers healthy and back to work and freeing up reserves. This is leading to unnecessarily high costs for payers.

Claims organizations need to figure out how to achieve the goals of maximizing provider networks and implementing predictive analytics in a way that will help adjusters do their jobs better, not further overwhelm them.

Expert panelists will address the following talking points:

  • Workload: Taking the adjuster’s workload and work process into account in maximizing the use of provider networks.
  • The Code Problem: The number of federal procedural and diagnostic codes is set to explode in October. How can organizations and adjusters manage this huge increase in complexity?
  • The Use of Data: Using predictive analytics to complement adjuster case management, not impede or replace it.
  • The Adjuster’s Role in Case Management: Getting the best treatment for injured workers, closing claims promptly and getting injured workers back to work sooner.

Recording

Download a copy of the slide presentation here.

Dan Reynolds is editor-in-chief of Risk & Insurance. He can be reached at dreynolds@lrp.com.
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View From the Bench

Workers’ Comp Docket

Key workers' comp legal decisions from around the country.
By: | April 11, 2014 • 10 min read
Docket

Employer of Undocumented Workers Protected From Liability Suit

New York Hospital Medical Center of Queens v. Microtech Contracting Corp., No. 00897 (N.Y. 02/13/14)

Ruling: The New York Court of Appeals held that an employer was shielded from a third-party claim for contribution and indemnification.

What it means: In New York, the fact that an employer illegally hired undocumented workers will not annul the employer’s statutory rights of being shielded from a third-party claim for contribution and indemnification.

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Summary: New York Hospital Medical Center engaged Microtech Contracting to demolish a basement room housing an incinerator. Two workers, who were undocumented aliens, were hired to perform the work. The vibrations of the tools used by the workers dislodged a metal chimney attached to the wall. The chimney toppled, striking and injuring the workers. Microtech’s insurance carrier paid workers’ compensation benefits to the workers. The workers also sued the hospital. The hospital brought an action for contribution and indemnification against Microtech. Microtech asserted that the hospital’s action was barred. The New York Court of Appeals held that Microtech was shielded from the hospital’s action.

The workers’ compensation law bars third-party suits for contribution and indemnification against an injured worker’s employer unless the worker suffered a “grave injury,” limited to death and an exclusive list of disabilities, or the employer agreed to contribution and indemnification in a written contract entered into with the third party before the accident. The hospital argued that the employment contracts between Microtech and the workers were illegal and unenforceable. The hospital asserted that Microtech could not defend the action on the ground that the workers were its employees and the workers’ compensation law barred the action.

The court explained that the illegality of the employment contract did not annul Microtech’s statutory rights. Also, the workers did not suffer grave injuries, and there was no preexisting agreement for contractual contribution or indemnification. The hospital did not contend that the Immigration Reform and Control Act preempted the workers’ compensation law. Therefore, Microtech was entitled to the safe harbor.

What Happens When TTD Benefits and PPI Benefits Collide

Moore d/b/a Cat Dog Trucking v. Jerrell, No. 93A02-1308-EX-00693 (Ind. Ct. App. 02/07/14)

Ruling: The Indiana Court of Appeals held that a worker was entitled to permanent partial impairment benefits for 500 weeks.

What it means: In Indiana, an employer is not entitled to a credit for temporary total disability benefits it paid to a worker that overlap with permanent partial impairment payments.

Summary: A worker for Cat Dog, a trucking company, was at work when his clothes caught on fire, causing him to suffer burns to 51 percent of his body. One of his legs was amputated above the knee, and the other leg was amputated below the knee. His left hand and arm were seriously impaired. Cat Dog paid him temporary total disability benefits. Eventually, a dispute arose regarding the nature and scope of the relief to which the worker was entitled. Later, the worker moved into a home with his mother, and Cat Dog paid the worker compensation for his mother’s care of eight hours per week. The Indiana Court of Appeals held that the worker was entitled to permanent partial impairment benefits for 500 weeks.

Cat Dog argued that since the worker elected to receive PPI instead of permanent total disability benefits he could not receive his benefits over a period of 500 weeks. The Workers’ Compensation Board pointed out that if the worker received his benefits in the way Cat Dog proposed, payment of his impairment award would take 28 years. The court found nothing in the law prohibited the payment to be made over 500 weeks.

Cat Dog also asserted that it was entitled to a credit for TTD benefits it paid to the worker. The court found that the law did not require a credit to Cat Dog for TTD payments that overlapped with PPI payments. The court pointed out that Cat Dog was credited for TTD benefits it paid after the worker’s injury was “permanent and quiescent.”

The court also rejected Cat Dog’s argument that it should receive a credit for the home health care services it provided to the worker. The court declined to reweigh the evidence.

Icy Slip and Fall Linked to TMJ Syndrome

Vance v. DCCCA, Inc., No. 109,294 (Kan. Ct. App. 01/31/14)

Ruling: The Kansas Court of Appeals held that a worker was entitled to benefits for her temporomandibular joint syndrome caused by her work-related accident.

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What it means: In Kansas, a worker’s delay in seeking treatment will make it difficult for her to establish that her condition was caused by the accident.

Summary: A family support worker was leaving her employer’s office to take some children back to their foster homes when she slipped on ice. She claimed that she injured her teeth, jaw, hip, back, and ribs on the concrete. The worker sought workers’ compensation benefits. The employer agreed that she sustained a work-related injury as the result of an accident arising out of and in the course of her employment. The Kansas Court of Appeals held that she was entitled to benefits for her jaw injury.

The court concluded that the worker established that her temporomandibular joint syndrome was caused by the accident. Multiple doctors diagnosed her with TMJ. A doctor’s opinion established a causal connection between the worker’s TMJ and the accident. The worker’s incident report with the employer stated that she bruised her jaw and chin. She consistently complained of jaw pain.

The court found that the worker failed to prove that her loss of dentition was caused by the accident. A dentist’s testimony did not establish trauma as the cause of her dental problems as opposed to decay. The court also pointed out that the worker did not visit the dentist until two years after her accident. The dentist opined that he was not in a position to state whether her condition was work-related. A doctor’s opinion was not reliable because he saw the worker after an intervening assault and more than one year after the dentist repaired her dental problems.

The worker failed to prove that she sustained permanent injuries to her low back and hip as a result of the accident. Substantial evidence showed that the worker’s hip and low back injuries were temporary. Although she initially complaint of back pain, she did not mention it in a later appointment with her doctor.

Employee Who Blew Off Safety Rules Awarded Benefits

Renfro Electric v. Sexton, No. 111711 (Okla. Civ. App. 01/10/14)

Ruling: The Oklahoma Court of Civil Appeals held that a journeyman was entitled to temporary total disability benefits.

What it means: In Oklahoma, a worker’s injury resulting from his negligent or dangerous failure to follow specific safety rules, regulations, or procedures is compensable when evidence shows that the worker had no intention of injuring himself.

Summary: A lead journeyman for Renfro Electric worked on the roof of a two-story structure. Instead of using a ladder to reach the second story roof, he directed that he be lifted to the roof by a materials lift. As the journeyman stepped from the lift to the roof, he fell and sustained significant injury. He admitted that the lift was not intended to lift workers and knew that such use was dangerous and contrary to Renfro Electric’s instructions. He asserted that because the ladders were not rated to bear his 350-pound weight, the lift was more appropriate. The journeyman sought workers’ compensation. Renfro Electric denied liability for the claim. The Oklahoma Court of Civil Appeals held that he was entitled to temporary total disability benefits.

Renfro Electric argued that the journeyman’s injury constituted “an injury occasioned by the willful intention … to bring about injury to himself,” and as such, the claim was barred. The court explained that even if an injury results from a worker’s negligent or dangerous failure to follow specific safety rules, regulations, or procedures, where the testimony shows that he had no intention of injuring himself, the claim is properly allowed.

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In this case, the journeyman admitted that the lift was not intended to lift workers and he knew that such a use was dangerous and contrary to safety rules and Renfro Electric’s instructions. However, while his disregard for his own safety may have been negligent and dangerous, there was no evidence that he “willfully” intended to injure himself.

Delayed Treatment Claim Subject to Exclusive Remedy Doctrine

Holt v. Dana Light Axle Manufacturing, LLC, No. 2013-CA-000287-MR (Ky. Ct. App. 02/14/14, unpublished)

Ruling: In an unpublished decision, the Kentucky Court of Appeals dismissed a worker’s suit against his employer, finding that workers’ compensation provided his exclusive remedy.

What it means: In Kentucky, a worker’s claim alleging that his employer negligently delayed his medical treatment falls under workers’ compensation.

Summary: A worker for Dana Light Axle Manufacturing experienced chest pain while on the job. He notified his supervisor, who did not send him to the on-site medical facility or any other emergency medical personnel. He was persuaded to go back to work. Three hours after he first reported having chest pain, the worker left work and drove himself to the emergency room. The following day, a stent was placed in his artery to improve blood flow and relieve his chest pain. The worker sued Dana Manufacturing, alleging that it negligently failed to allow to him seek medical care, resulting in increased damage to his heart and psychological trauma. The Kentucky Court of Appeals dismissed the suit, finding that workers’ compensation held his exclusive remedy.

The court explained that the injury was not the worker’s heart attack itself but the potential increase in damage to his heart resulting from the delay in treatment as well as the alleged psychological trauma that accompanied his decision to leave work. The court found that the worker’s injuries arose out of and in the course of employment. The delay in receiving medical care and the psychological injury were the result of activity related to his employment.

The court said that if the worker had not been at work and subject to Dana Manufacturing’s on-site medical services facility he might have received more expeditious medical care. The worker’s injuries may not have occurred had he not been at work.

Company Veep Denied Comp for Lobby Wipeout

Grace v. Himes Consulting Group, 21 ILWCLB 212 (Ill. W.C. Comm. 2013)

Ruling: The Illinois Workers’ Compensation Commission denied benefits to a vice president for an injury sustained when she fell in the lobby of the building where her employer’s office was located.

What it means: In Illinois, a worker’s injury in the lobby of a multi-tenant building in which her employer leases office space does not arise out of her employment when the employer does not have exclusive use of the common areas and is not responsible for maintaining such areas, the employer exercises no control over where the worker enters the building, and the lobby is open to the public.

Summary: On her first day of work, a vice present of sales entered a multi-tenant office building where her employer leased space. She walked to the elevator and fell, injuring her right knee and ankle. The vice president testified that the lobby floor was marble and slippery, and she noticed it had some fine, chalky dust on it. The commission affirmed and adopted the decision of the arbitrator denying benefits.

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The lobby was a common area of the building. The employer’s lease provided that it did not have the exclusive use of and was not responsible for maintaining the entrances, lobby, elevators, and hallways of the building. These areas were open to all tenants, visitors, and the general public. The employer exercised no control over where the vice president entered the building, the area where she fell, or the route she took from the street to the employer’s suite.

The arbitrator explained that the vice president’s accident involved a neutral risk and concluded that the vice president was not exposed to a greater risk by walking through the building’s lobby because the lobby was used by the general public. Therefore, the vice president failed to prove her injuries arose out of any risk connected or incidental to her employment.

Christina Lumbreras is a Legal Editor for Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at riskletters@lrp.com
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Sponsored: Aspen Insurance

Minimize the Risks of Client Lawsuits

Approach client communications as if you were writing directly to a future jury. If a client ever sues, it could save the day.
By: | April 7, 2014 • 4 min read
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When a top litigator prepares a case for a trial, part of the process is mapping out a clear, written story to put in front of a jury. Professionals looking to avoid or minimize the impact of client lawsuits would be smart to follow that lead, according to Christopher Piety, underwriting counsel, Professional Lines Risk Management, Aspen Insurance.

“Just like when a talented lawyer faces a jury, the better prepared you are, the stronger your case will be and the more likely you will prevail,” Piety said. “That means being very clear when writing an email or a letter to a client. Approach these communications as if you were writing directly to a future jury.”

Piety explained that in the wake of several recent sizeable professional liability claims, lawyers and other professionals (i.e., accountants, architects and engineers) must deliver clear, concise written communications, to create a record of what happened along the way. “On some of the larger claims that I’ve been involved in, whether it is with lawyers, accountants, architects or engineers, it really boils down to managing client expectations. And to do that requires effective written documentation,” he said.

For example, Piety said that in a recent professional liability claim, a lawyer did nothing wrong other than failing to put into writing advice that the circumstances of the client’s case changed, which typically translates to an added risk that the desired outcome may not be achieved.

SponsoredContent_Aspen“When you write an email or letter, it’s critical to include specifics. It will go a long way to avoid potential trouble, especially if the situation ends up in court,” Piety said. “A good defense is a strong offense.”
– Christopher Piety, underwriting counsel, Professional Lines Risk Management, Aspen Insurance

“The attorney didn’t spell out in writing that the evidence no longer supported the client’s seven-figure expected outcome,” Piety said. The client eventually dropped the case and then sued the lawyer for malpractice, claiming that the attorney’s failures cost them a positive result. Without written documentation advising the client about the risks, the attorney could not prove the client had been advised.

Screen for Bad Apples

“Professionals need the courage to ‘fire’ a potential problem client should any serious red flags emerge,” Piety said. “Not every piece of business is a good one.” Along those lines, he offered a few bits of advice to avoid potential problems when choosing clients:

  • Obvious Red Flag: A potential client that “burned through” multiple professional services firms. Worse, have they sued any of them?
  • Reputation Check: After completing a credit check and/or litigation search, research the potential client’s reputation in the local business community.
  • Financial Stability: Check to see if the client is financially sound.  Sometimes, problem clients manage to transfer their financial problems to their professionals in the form of unpaid fees and/or malpractice claims.
  • Available Staff: Make sure your firm is prepared and staffed to properly do the work requested.

Clarity is Critical

“When you write an email or letter, it’s critical to include specifics. It will go a long way to avoid potential trouble, especially if the situation ends up in court,” Piety said. “A good defense is a strong offense.”

SponsoredContent_Aspen

Professionals need to carefully detail the scope of work when starting a new project or case, particularly if the client is also new. From a risk management perspective, it’s most critical to completely outline limitations and risks.

In addition, specific risks to various types of professionals may include:

  • Law Firms: Never offer guarantees for specific results, and understand that silence can be interpreted by a jury as agreeing with a client’s unrealistic expectations.
  • Architects and Engineers: Specify what you will and will not be responsible for. Never agree to indemnify anyone outside the firm.
  • Accountants: Advise clients and others using your work that attest engagements only provide limited assurance of no material misstatement in the financials, but do not guarantee the absence of fraud or financial problems with the attest client’s business.

Communicate Frequently

“Throughout the entire business relationship, it’s a good idea to document any ongoing changed circumstances, no matter how seemingly small, and advise clients of any new related risks and/or performance limitations,” Piety said. He outlined these examples:

  • Accountants: Quickly advise clients in writing when the client’s own poor record-keeping is causing the audit work to be more expensive and/or creating risk of material misstatement requiring additional client action.
  • Lawyers: Advise clients in writing when discovering evidence that may potentially change the value of the case.
  • Architects and Engineers: Communicate in writing when change orders on a project require expensive design changes that may negatively impact the overall project budget.

“Just like when a talented lawyer faces a jury, the better prepared you are, the stronger your case will be and the more likely you will prevail. That means being very clear when writing an email or a letter to a client. Approach these communications as if you were writing directly to a future jury.”

Act Promptly

Piety said the failure to act quickly often causes confusion, which can in turn lead to unnecessary and unforeseen problems. To stop that from occurring, he offered these insights:

  • Communicate immediately, via writing, any emerging issues that affect a client’s expectations and your ability to meet them.
  • Clients who fail to pay in a timely manner or seem unhappy early on in the relationship probably have an issue that should be addressed immediately.

In the end, only by having a clear written record of what actually occurred can professionals ensure they will reduce, or even prevent, the threat of a claim. Do not give your future opponent an opportunity to fill in the gaps with their own version of reality designed to sway a jury against you.

“Always focus on the fundamentals because fundamentals are what will really help a defense,” Piety concluded. “In so many cases, written communication will prove to be the critical factor between winning and losing.”

This article was produced by Aspen Insurance and not the Risk & Insurance® editorial team.
This article is provided for news and information purposes only and does not necessarily represent Aspen’s views and does constitute legal advice. This article reflects the opinion of the author at the time it was written taking into account market, regulatory and other conditions at the time of writing which may change over time. Aspen does not undertake a duty to update the article.

Aspen Insurance is a business segment of Aspen Insurance Holdings Limited. It provides insurance for property, casualty, marine, energy and transportation, financial and professional lines, and programs business.
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