Thursday, May 9, 2013

How a Claim Goes Catastrophic

Yesterday I wrote about Martha, an emotionally trying case that warranted the most expeditious claims handling that could be mustered, and was successfully jettisoned from the claims process to the betterment of her, the employer, my client and the system in general.

About 12 years after that I was doing defense work at another young law firm that was growing rapidly and aggressively. Those qualities fit my legal style too, so I fit right in to the culture for my short duration there.

Early on I was assigned a "catastrophic" case file.

Those of you in who are in claims know what a catastrophic file is - where certain qualities denote very high expenses and very high indemnity values, typically where there is a very real possibility of a 100% award.

This particular file had been around the block several times. The file itself was about 3 feet thick, literally, and the claim had, from my point of view, been mismanaged from day one.

Over the five year life of this claim, prior to my arrival, there had been no less that ten claims adjusters.

My initial review of the file astounded me as I saw a very basic soft tissue back injury claim morph beyond all reason to include nearly every part of the body imaginable, with surgery to something or the other nearly every 6 months.

The claimant himself was described as a nice man who was not fraudulently taking the system for a ride, but who experienced complications at every turn of treatment - nothing went right for this gentleman.

Obviously this raised my eyebrows - in my mind we weren't dealing with someone who actually had physical maladies, but for the malfeasance exacted upon him by non-caring physicians interested only in using this man as a billing statement.

No, we were dealing with someone who would be more appropriately be categorized with a mental health issue.

It was clear to me that we were dealing with some sort of a somatoform disorder and why no physician dealt with this head-on (pun intended) was akin, in my mind, to malpractice.

Regardless, it became my job to deal with this mess.

The claimant didn't start out all that injured or all that disabled. But after surgery upon surgery, and disability upon disability, this claimant truly was physically disabled. Now the issue became how to extract this individual from the workers' compensation system that had done him so much harm, in as expedient manner as possible.

And, I might add, at whatever short-term cost. At least in my mind. Because it was clear to me that whatever the closing price of this case was going to be, it would be a whole lot cheaper than maintaining this gentleman on the disability roles and subjecting him to more medical treatment.

Fortunately the claims adjuster that was on the file at the time I was assigned the matter had the good sense to put a nurse case manager on the file, and the nurse case manager had the good sense to coordinate all of the physicians so that they were actually cooperating towards some reasonable medical goal for this guy.

A good start.

I got that nurse case manager and the claims adjuster on the phone for a strategy talk and we came up with a game plan that incorporated the medical and the legal aspects. I then prepared for my client, in order for her to run the matter up the bureaucratic flag pole for approval, a very lengthy and detailed litigation plan, including estimated costs and a return on investment profile.

Honestly, this far down memory lane, I don't remember what that plan entailed, but I do recall that it received approval from as far up the totem pole as was necessary for such expenditures.

I had the nurse case manager behind the plan and I had the adjuster behind the plan. Ultimately I would start to get the cooperation of the applicant attorney and his client behind the plan too (though of course the plan they received did not contain sensitive attorney work product or attorney-client communication).

For the first time in the history of this claim it appeared that we had some control over the situation - the applicant was actually starting to get better! We targeted towards a permanent and stationary date and it looked like that was going to happen.

I worked that file religiously, making sure everything that needed to get done happened - whether it was medical reporting, timely payment of bills, communication with the treating physicians - I had that claim under control and I could smell file closure getting close.

Then one day I made a call to the adjuster for some authorization for something or the other. Gone. Reassigned. Never to be heard from again.

I asked for a supervisor - tough luck. Even the supervisor's supervisor couldn't (or wouldn't) help me.

The case floundered for a couple of weeks - the worst thing that could happen to a case like this in my mind. This was the type of case that required constant attention because any little excuse for this claimant to get to a doctor for more treatment would result in catastrophic consequences.

The somatic personality is not one to mess with!

Eventually a new claims adjuster made it on the file. The last thing this adjuster wanted to do was pour through a 3 foot thick file.

And, as I came to find out, apparently didn't want to even read my claim management plan.

Suffice to say, after getting this claim under control over the course of about 5 months, and seeing the light at the end of the tunnel, the entire claim blew up.

I had lost control.

It reminded me in my early bicycle racing days at the Manhattan Grand Prix - circa 1984 or so. The peloton was 130 strong, but I was at the peak of my skills, strength and endurance. I was CONTROLLING that race. Every preme sprint, every block, every move was mine. The race was in the bag.

Until with about 10 laps to go I found myself mid peloton on the inside of a right hand sweeper thinking to myself, "this is a bad position and I need to move out of ..." BAM! CRASH! OUCH! followed by lots of bodies and bicycles on the ground and on top of each other - me included.

My bike was bent. I was bloodied. And I was out of the race and of couse mad at myself because I KNEW I was in a bad position and I had let myself get there.

Bicycle racing is an odd combination of cooperation and competition. Everyone relies on the other to conserve energy and build speed, and this requires everyone to work together and also to be alert to conditions to minimize the risk of disaster. But everyone is competing against each other too.

On the bicycle on that day at the Manhattan Grand Prix from my point of view it was my error, my fault, for being in a position of disaster.

But in the world of claims administration, there was nothing I could do. I managed the case as best I could, but it required the cooperation, and coordination, of several other people and if they weren't interested in maintaining safety then there was going to be a crash - and indeed, that is what happened.

I left that firm shortly after to start WorkCompCentral but remained in communication with the attorney who took over the case. Four or five years after I left I asked that attorney what was going on with the case.

It was still ongoing, and had been through another three or four adjusters - all just as complacent and disinterested as the one that took over after I got on the case.

The billings must have been tremendous...

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