Spinning True Tales of the Claims Universe

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.

By Adjuster X

Welcome to Adjuster X. This column is based on the experiences of a small group of claims adjusters who have seen it all: from "injured" employees miraculously walking without crutches to relatively minor injuries that snowball into complex claims. We will respect our employers and the privacy of the people involved by not revealing our names or the names of people in our stories. We assure you, however, that these are actual experiences from our long careers.

For our first column, let's look at what happened when two construction workers crossed state lines for work and found themselves in the midst of a downpour. Because the rain made it impossible to work, their boss told them to find some shelter. So they decided to have lunch at a local tavern. The beers began soon after, and the two began to get drunk. By 3 p.m., as they were playing a game of pool, tempers flared and they started arguing. Finally, one of the workers struck the other in the head with a pool stick, dropping him to the ground.

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The worker suffered a concussion and a subdural hematoma -- bleeding underneath the skin that can cause pressure on the skull. The injury could have been fatal if the swelling had not been relieved, and it led to high medical bills. The employer's insurance policy had an endorsement for the state where the incident occurred. That was a blessing. At least it was not a situation where there was no workers' comp coverage in the state where the incident transpired.

Originally, I thought there was no way that a bar fight could be compensable for workers' comp. Their behavior was not only irresponsible but it clearly deviated from the course of employment. But the case law in that state is more aligned with behavior people might reasonably be expected to exhibit. What do you expect a couple of construction guys to do, hang out and drink tea? (Oh, please. Perhaps that state doesn't have a high regard for construction workers and their commitment to sober employment.)

The biggest reason it was compensable was because they were working out of state and had an employer-paid hotel room and food stipend. That entitled them to 24-hour workers' comp benefits, regardless of where they went or how they acted. Miraculously, the employees were even able to prove that the argument was about work, since the bartender said he remembers them arguing about a certain construction technique. While it may be laughable to think that it wasn't the combination of booze, competition and testosterone that led to the fight, but rather a high-level discussion about the proper way to install wooden cross beams -- that's just how the court ruled. There was no negligence on the bar's part, no liquid on the floor that the construction workers could have slipped on and they weren't over-served. In fact, the bartender had already asked them to leave.

In the end, it was ruled that their drunken bar brawl was directly related to the furtherance of the employer's business. Successfully arguing that the two employees should not have spent the afternoon in a bar imbibing was no easy task. In a nutshell, the court said, "Thank you for moralizing, but the man suffered severe head injuries, will have trouble working in the future and could have died. We're pleased with your ethics, now get your checkbook out."

JARED SHELLY is the editor of this column and can be reached at jshelly@lrp.com

February 19, 2013

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