The claim seemed average enough. A 37-year-old male employed by a factory claimed to have injured his right arm when picking up a 50-pound basket of tools. He said the arm was now numb and couldn't be used. The injury appeared to be soft tissue in nature.
I thought it was perhaps an ulnar nerve issue.Scott, the employee, had seen a doctor, who ordered him off work until further examinations could be completed. X-ray results were negative.
I met the employee at his house. The way the injury occurred seemed straightforward enough, but something was off.
After the interview, I outlined what benefits he could expect to receive.
Next, I went to speak with Scott's supervisor. He confirmed there had been no witnesses to the incident. Scott had come to him with his right arm "dangling" by his side, claiming he had picked up the basket and his arm went numb. He told Scott to go to the company-designated doctor.
I called the doctor's nurse, who confirmed that the X-ray was negative for a fracture. However, Scott exhibited a very weak pulse and low blood pressure on the right arm, although the left arm readings were normal. The doctor ordered more tests.
The additional tests turned out to be negative. However, Scott continued to claim his right arm was numb. The doctor asked him to report back to the office. Upon examination, the pulse and blood pressure of Scott's right arm were still very weak. Afterward, the doctor called me to say he was baffled, but suggested calling in a neurologist or vascular expert.
I had three days to make a determination of compensability. There was no way the additional evaluation was going to be made within that timeframe. It looked like I had no choice but to issue a check -- but then I had an idea.
I asked the nurse to meet me at the plant and to bring a stethoscope and a blood pressure cuff. Next I called the plant and asked the foreman if it was okay to have Scott come in to discuss his case. I asked the foreman to attend the meeting.
I didn't call Scott until 9:30 the next morning. I told him that I had my checkbook with me and would issue him a TTD check after he answered a few more questions. He complained about the short notice, but showed up.
I met Scott in the foreman's office. I asked for the nurse, who was in the next room, She checked his blood pressure and pulse, and both were normal. There were no physical findings to substantiate Scott's complaints.
Scott accused me of ambushing him. "Come on, Scott," I replied. "You know what you did." His face got red. I continued, "The symptoms you exhibited were self-induced, weren't they? You probably tied a band or rubber hose around your upper right arm just before you saw the doctor each time."
Scott began yelling, "You can't prove that! You aren't a doctor!"
The foreman glared at Scott, "I expect you to be at work tomorrow at 7 a.m. You're lucky I'm not firing you here and now."
Scott stormed out of the office. The foreman and nurse both looked at me and said, "How did you know?" I said, "Adjuster's sixth sense. Something about the symptoms led me to think they might be self-inflicted."
They both shook their heads as I left the office.
MICHELLE KERR is the editor of this column and can be reached at email@example.com. 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.
October 1, 2013
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