The Connection Magazine AIM MUTUAL Spring 2020 | Page 5

When the Story Doesn’t Add Up
By: Candace Wilusz, Claim Supervisor
WHILE IT’S easy to see why the truly catastrophic cases
leave a lingering impression, for me, it’s a case of a very
different nature that comes to mind.
It involves some forensics, a diligent employer questioning
the facts, and—we later learned—an iguana.
While cutting wood with a router saw, an employee
sustained a partial amputation of his thumb. He reported
the accident right away, saying he’d been prepping the first
router table by brushing off excess laminate dust in order to
perform his normal work functions when he accidentally hit
the start button.
At first blush, it looked like a textbook example of what
the workers’ compensation statute was enacted for.
As we always stress, the owner immediately discussed
the accident with the supervisor and office manager, who
had been present but did not actually witness the injury. The
supervisor felt something just didn’t add up with the time of
the accident and the manner in which the loss had allegedly
occurred. Because of this, the policyholder had the presence
of mind to view the accident scene, where the visual evidence
told a very different story.
A blood trail remained, and it was not limited to the router
table the employee said he was using. In fact, it led to a
second table that should not have been in use at the time. The
spatter on the floor around the second table was far greater
than it was at the first table. A further search revealed pieces
of wood, one with blood on it, clearly being assembled for a
personal project. That project was suspected to be a cage
for his girlfriend’s pet iguana.
We were told that employees are allowed to use the
equipment for personal use on occasion; however, it’s limited
to breaks and personal time. This serious accident, however,
occurred during work hours. Based on the facts of the
investigation, which our claim team confirmed, the claim was
denied and never pursued further.
I use this claim as a teaching case for a couple of reasons.
First, it demonstrates that the devil is in the details, and
a thorough investigation and examination of the facts
is necessary on every claim. You can’t assume a claim is
compensable because it appears that way on the surface.
Second, it shows the importance of our partnership with
employers. They are our first line of defense. They help bolster
our investigation of the facts by immediately talking to those
who were present, taking photos, and preserving the accident
scene. The key is to remember that, if something doesn’t
appear to add up, it’s a red flag: follow that instinct.
LENA
DECHRISTOFORO
LENA
DECHRISTOFORO,
Senior Claim
Supervisor, has
supervised workers’
compensation claims
for A.I.M. Mutual for
more than 20 years.
She also has extensive
prior experience
handling multi-lines
claims in adjuster
and supervisory
capacities. Lena holds
an Associate degree in
Business Management
from Aquinas College.
CANDACE
WILUSZ
CANDACE WILUSZ,
Claim Supervisor, has
specialized in workers’
compensation claims
since 1989, first with
Liberty Mutual and
then with A.I.M. Mutual
in 1995. She assumed
a supervisory role in
2007. Her training focus
has included fraud
identification, case
pricing, and settlement
negotiations. She holds
a Bachelor of Arts
degree in Spanish from
Wheaton College.
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