I write all the time about bad things in workers' compensation and how we need to give the world something positive to talk about. Just yesterday I commented on the medical fraud mill in Southern California. The day before that it was about a professional football player that endured decades of delay and denial until he got the medical care recommended by the insurance company's consultant.
Every day there's something negative reported. The whole institution of workers' compensation seems ensconced in delay, denial, refusal, dispute...
This negativity wears on the psyche. People in workers' compensation seem embarrassed to be associated with the industry because of these bad perceptions. Everyone has a neighbor who's "cheating" because they can mow the lawn while out on disability. Doctors don't listen to their patients because they're not paid to do so and can't afford the time if they are to stay in business. Lawyers, even for the defense, get disheartened because financial control takes precedence over return to health.
Even claims adjusters, those who are really on the front line, end up with inferiority complexes, despite doing the right thing.
The tone in the prose of "Adjuster X" in the latest postings in Risk and Insurance's website seems apologetic, even depressing - because he did the right thing against the wishes of his superiors, the broker and the employer.
You can tell by reading his tale that he KNOWS the right answer to his claim question right away: accept or deny. And you can feel his angst as he tries to do his job, correctly and appropriately with sound decision making within the bounds of the law and the description of his job.
The facts seem to me pretty straight forward and point to compensability.
The injured worker, a 54 year old nurse case manager, was driving from one appointment to another when she was involved in a serious rear-end auto accident. She was not wearing a seat belt. She was also, apparently, considered a marginal employee, good enough but not great.
The broker demanded the adjuster deny the claim because of the lack of safety belt, obviously not understanding that workers' compensation is a no fault system. "I told him that my investigation was still ongoing," writes Adjuster X, "and any decision now would be premature," too polite to tell the uneducated broker that negligence has no basis in comp (although in this state apparently benefits could be reduced by 25% for lack of a safety belt in an auto accident).
It appears that after about two weeks of hospital care the adjuster gets a demand letter from an attorney representing the employee demanding the claim be accepted, and after consultation with house counsel Adjuster X ultimately did accept the claim and started paying benefits.
After 10 months the employee's condition didn't improve, and her attorney amended the claim to include psyche and total disability. Opposing medical-legal exams ensued with predictable results.
"Further defense of the case would be time consuming and costly," Adjuster X concludes, "so reluctantly we accepted the case for lifetime disability."
When I read the account by Adjuster X, I hear embarrassment at not meeting the demands of the employer and its broker. I feel anxiety and conflict in knowing someone's life was inescapably altered and who's future is in his hands. In the conclusion I glean relief: decision made, time to move on, another case of heart wrenching decision making processes to take its place.
It's easy to denigrate and criticize "the insurance company" because of the monolithic facade of the establishment, and the cold, dehumanizing character of the process.
But behind that steel and glass are real human beings entrenched in conflict as soon as they walk through the doors to do their jobs. Every day the professional at the claims desk has decisions to make that affect, deeply, others.
The pressure comes from the broker and employer who aren't educated or experienced in the nuances of workers' compensation law or have some ulterior motive. There's pressure from corporate to meet financial and compliance goals. The threat of litigation adds an additional layer of pressure.
And, "reluctantly," the claims adjuster has to decide between the financial interests of his employer or the humanitarian interests of his ward, the injured worker.
In the end, Adjuster X did the right thing.
Not without considerable anxiety, stress and internal conflict - all of which is palpable in Adjuster X's story.
The employee is likely one for the rolls, and the case file will migrate from adjuster to adjuster through the years to administer lifetime benefits and medical care, likely with no less anxiety, stress and conflict for the successive adjusters.
In my mind, though, Adjuster X made the workers' compensation process function as intended - to me this is ultimately a success story.
There are many more success stories like Adjuster X's, where the right decision is reached through the discord and contention that is inherent in the claims process. We need to recognize those stories and the people that make them happen.
“There are a lot of more positive narratives out there—but they’re lonely, and disconnected. It would make a difference to join them together, as a chorus that has a melody.” Phillip Zelikow, a professor at the University of Virginia, to journalist James Fallows in “How America is Putting Itself Back Together.”
Comp Laude™ 2016 will happen in Burbank, CA Nov 4 & 5. I hope you will share your success stories and celebrate those of others.