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 26 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