The Connection Magazine AIM MUTUAL Fall 2019 | Page 26

MANAGING COMPLEX CASES
LESSONS LEARNED
IN WORKERS’
COMPENSATION CLAIMS
In Part 2 of our series on claims that made their mark, A.I.M. Mutual supervisors discuss
why these cases are so valuable in training and how they resonate years later.
One Shortcut Changes Lives
By: Lisa Battis, AIC
Regional Claim Specialist Supervisor
I’LL NEVER forget “Jim,” a maintenance
worker who was highly dedicated to
his job and even used to walk to work in
snowstorms when others couldn’t get
there. He knew the plant like his own home.
One day he climbed onto a stool instead of
using a step ladder and slipped. He injured
his back and never returned to work.
Jim had preexisting back injuries, and
this incident—which appeared minor at
first—resulted in a drop foot, impairing
his ability to walk. He had surgery, but
unfortunately, his injury continued to be
disabling. Nonetheless, he was always
upbeat and wished he could return to
work. (His wife did, too!)
I visited him on a regular basis, checking
in on him and trying to settle his claim.
He never did accept an offer, content to
receive his weekly benefits.
I use this claim in training to
demonstrate how important it is to remind
policyholders to promote safety at their
job sites. Even those employees who
know their jobs inside and out can still get
injured if they take shortcuts. This claim
made me very aware of how a work injury
can affect an employee’s life and family
members’ lives in so many ways. Since
then, every time I get a new assignment,
I remember that a work-related injury
affects more than one person; it can alter
an entire way of life for a family.
Researching the Law
By: Aram Kalashian, Claim Supervisor
This claim made a lasting impression
because it taught me the value of
investigation, researching the law,
and following litigation through to its
conclusion.
This case was tragic: a death case
involving an intoxicated employee. Due
to flooding in the surrounding area, it
appeared the employee was onsite to
operate a water pump to safeguard the
business. However, the pump was never
started. Sadly an autopsy confirmed
the employee, whose blood alcohol
concentration was more than five times
the legal limit, had drowned in standing
water.
As the carrier, we felt the employee
could not have been “in the course and
scope of his employment or was a benefit
to the employer” considering the high
blood alcohol level; therefore, this was not
a compensable workers’ compensation
case.
The judge disagreed, ordering benefits
paid under Section 7(A) of the law. That
law, in summary, says that if an “employee
is found dead at his place of employment,
and is unable to testify . . . it shall be
prima facie evidence that the employee
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was performing his regular job duties on
the day of injury or death.” The claim was
ultimately lump sum settled.
Still, given the prior medical history,
we had one more legal avenue: pursue
recoveries via the Second Injury Fund.
That, in fact, allowed us to recover more
than half of the benefits paid (63.75%,
close to the maximum allowed).
I use this case for training all the time.
It illustrates three key sections of the law
in Massachusetts: §27 Willful Misconduct
of an Employee, §7A Presumptions—
Employee unable to testify, and §37
Second Injury Fund recovery. This case
has taught me to look deeper into possible
Second Injury Recoveries and conduct
more case law research on my files.
The Opioid Red Flag
By: Keith Mailloux, Claim Supervisor
It appeared to be a clear-cut workers’
compensation claim. A Licensed Practical
Nurse (LPN) was propping up a patient to
dispense medication when the patient
fell backward. The LPN reported she
torqued her shoulder and lower back and
went immediately for emergency medical
treatment. These types of injuries are
not uncommon in healthcare. We paid the
claim as it appeared to be a compensable
injury that arose out of and in the course
and scope of her employment.
This claim happened in September