NJ Workers’ Compensation Case Studies THREE CASE STUDIES Presented by Inservco Insurance Services September 30, 2016

CASE 1: THE DISASTER The claim involves a 45 year old male custodian who alleged he slipped and fell on ice in the employee parking lot at 6:30 a.m. The parking lot is leased and the employer is not responsible for maintaining the lot. The employee’s normal start time is 8:00 a.m. He had arrived at work early so that he could collect empty soda cans that he would then sell to a scrap metal recycling center.

The employee reported the alleged injury to his supervisor, but the supervisor did not believe the incident ever occurred or that it would be a workers’ compensation claim if it did occur, and therefore did not report it to anyone else. Since the employer did not report this as a workers’ compensation claim, the employee was able to seek unauthorized medical care by physicians of his choice.

After the injury, the employee began to treat with Dr After the injury, the employee began to treat with Dr. Smith on a monthly basis ($66.02 per office visit), who ordered an MRI of the lumbar spine ($450.00 radiologist and $958.83 facility fee) which revealed the presence of advanced degenerative disc disease at L5-S1. Dr. Smith immediately prescribed Morphine Sulfate ($1,821.50 per month), Actiq lozenges ($11,135.00 per month) and trigger point injections ($264.50 per month) to relieve the employee’s pain. He also ordered physical therapy to be performed five times per week ($3,811.39 per month) at a facility that he owns.

One month after the injury, the employee filed a first notice claim petition. Unfortunately, when the Notice of Assignment for the petition was received by the employer, the individual who normally handles such matters for the employer was on a 2 week cruise, and no one else knew what to do with it. Therefore, it sat on the employer’s desk with no action until he returned. It was then sent to the TPA for handling. The TPA claim representative sent the petition to defense counsel for handling.

When the TPA finally received the claim, they contacted the employer and found out that the employee had only worked for the employer for 6 months and had a negative balance in his leave time. He had just been disciplined for abusing his leave time and was on the verge of being terminated. This information was transmitted to defense counsel

In an effort to defend the petition, the TPA scheduled an independent medical evaluation with Dr. Jones. The claimant failed to attend the examination, and the employer therefore had to file a motion to compel. Dr. Jones charged the TPA $1,000 for a no-show fee. At the hearing on the motion to compel, the claimant’s attorney indicated they had no problem with attending the examination, but claimed that the employee could not drive and therefore would require transportation at the employer’s expense, which costs $450.00. The Judge advised the employer to make the appropriate arrangements, which they did. There was a $2,000 charge for this examination.

After finally examining the employee, Dr After finally examining the employee, Dr. Jones opined that the employee sustained a mild strain/sprain superimposed upon pre-existing degenerative disc disease. He indicated that the disc herniation was present prior to the slip and fall and there was no objective evidence that the fall aggravated his condition. Per his review of the records, the employee was fully recovered from the injury sustained in the slip and fall, but would need to restrict his activities due to the pre existing degenerative problems.

Six months after the petition was filed, both sides ordered permanency exams. The examiner for the petitioner opined that the fall was the cause of his herniated disc and assessed permanent partial disability at 50% or ($138,510). The defense examiner agreed with Dr. Smith’s findings and gave a permanency rating of 5% partial total( $ 6,340) The Judge of compensation found Dr. Smith to be more credible than the IME physician because Dr. Smith had seen the claimant numerous times compared to the one time the IME physician examined the claimant. In the order, the Judge indicated that the employee had an average weekly wage of $450, which equates to a compensation rate of $315 per week

At this time the employee had been out of work for 29 weeks and was therefore due $9,135.00 in temporary disability compensation plus a permanency award of 22 ½% ($33,967) for an un-operated herniated disc at L5-S1

indicated that there was no actual or potential lien for subrogation because defense counsel was of the belief that the fall had occurred on the employer’s premises. One month after the workers’ compensation claim was settled, the claimant filed suit against the owner of the garage, and that suit was eventually settled for $50,000 without the employer’s knowledge.

indicated that there was no actual or potential lien for subrogation because defense counsel was of the belief that the fall had occurred on the employer’s premises. One month after the workers’ compensation claim was settled, the claimant filed suit against the owner of the garage, and that suit was eventually settled for $50,000 without the employer’s knowledge.

In total, the employer paid: Medical 6 months $79,412 Temporary Disability $ 9,135 Partial Total Disability $33,967 Defense costs $ 5,000 IME fees $3,000 TOTAL $130,514

ISSUES All potential claims need to immediately be reported to the Insurance Carrier or TPA, whether or not the employer believes the claim to be compensable. The use of medical providers who understand workers’ compensation issues allows for better control of claims from the outset. If a petition is filed, immediately notify the insurance company or TPA. During the initial investigation of the claim, note all “red flags” that may indicate issues with the claim. Light duty jobs help to mitigate the exposure on claims.

Issues continued Issues regarding potential recoveries from third-party suits need to be fully addressed. Improper initial investigations can lead to benefits being paid on claims that otherwise would have been denied. In some cases, such as total disability payments can continue for life.

Case 2: Better Results The claim involved a 45 year old male custodian who alleged he slipped and fell on ice, injuring his lower back in the employee parking lot at 6:30 am on Friday, January 6, 2011. The parking lot was leased and the employer is not responsible for maintaining the lot. The employee’s normal start time was 8:00 a.m. He arrived at work early so that he could spread salt at the front entrance of the employer’s facility.

The employee waited until the following Monday to report the injury to his supervisor. When the supervisor asked why he did not report the injury when it originally occurred, the employee indicated that he thought he would feel better, but the pain actually became worse. The supervisor referred the employee to Dr. Dooright the authorized panel physician. Dr. Dooright had the employee complete a workers’ compensation medical questionnaire that included medical information pertaining to prior accidents, chiropractic care and recreational activities and the name of his family doctor. The Doctor took x-rays and diagnosed the employee with a lumbar sprain/strain and prescribed Hydrocodone and physical therapy. The employee was disabled from work.

The adjuster completed a full investigation including 24 hour contacts with the employer, employee and Dr. Dooright’s office. When the adjuster contacted the employee’s supervisor, she learned that the employee had only worked for the company for 6 months, had minimal leave time left and his work performance was average. The adjuster telephoned Dr. Dooright’s office and had him refer the employee to an orthopedist for continued treatment for casualty. He was referred to Dr. Smith.

During the interview of the employee, the adjuster learned that he had been involved in a non work related motor vehicle accident 2 years ago. Due to the injuries sustained in that accident, he had undergone a lumbar fusion. Dr. Smith was his treating physician for that injury. The employee received a large settlement and stopped treatment for his back 3 months before he started working for the employer. The adjuster sent a HIPPA authorization form to the employee to sign so that those medical records could be obtained and reviewed.

There was a witness to the accident, who completed a witness form confirming the employee’s statement. The adjuster accepted the claim for Temporary Total disability for a lumbar sprain/strain. His average weekly wage was $1,000.00 per week resulting in the compensation rate of $700.00 per week. There was subrogation potential so the adjuster sent the employee a lien letter placing him on notice of the employer’s right of recovery in the event the employee pursued a third party suit.

The employee followed up with Dr. Dooright who referred him back to Dr The employee followed up with Dr. Dooright who referred him back to Dr. Smith, despite the fact that he was not on the panel. Dr. Dooright made the referral because of Dr. Smith’s prior treatment of the employee, including the surgery to his lower back. In the meantime, the employee was advised to remain out of work. Since Dr. Dooright referred the employee to Dr. Smith, Dr. smith automatically becomes an authorized provider. The adjuster did not contest the referral.

The adjuster sent a letter to Dr The adjuster sent a letter to Dr. Smith’s office requesting all of the employee’s medical records, including those for treatment prior to the work related injury. The adjuster also asked if the employee could return to work in any capacity. The medical records were received by Dr. Smith’s office in a timely manner. They confirmed that treatment for the injury from the auto accident had ceased 3 months prior to him being hired. Dr. Smith recently ordered a MRI which showed no new herniations and released the employee to return to work with no lifting over 25 pounds. The employee was to continue physical therapy and Hydrocodone.

The adjuster forwarded the return to work form to the employer based on Dr. Smith’s light duty release. Unfortunately, the employer could not accommodate the employee’s restrictions at that time so the employee remained out of work. After he was out of work for a total of 5 months, the employer created a light duty position for the employee. When the employee returned to work, the adjuster stopped his indemnity benefits.

After a total of 6 months with minimal improvement, the employee was referred to Dr. Meds, pain management physician. Dr. Meds had the employee stop physical therapy and start on a course of epidural steroid injections. He indicated that if the epidural steroid injections helped, they would be continued every 3 months. The employee was to discontinue Hydrocodone and start Mobic. The employee was advised to continue working light duty with no lifting over 25 pounds.

The adjuster requested an IME when it was 9 months after the injury date because the employee‘s light duty position was going to end in the near future. The IME was scheduled 2 months later with Dr. Jones. Dr. Jones indicated the employee could return to work full duty, but was not fully recovered from the work injury. This was due to the aggravation of degenerative disc disease, status post lumbar fusion. Dr. Jones recommended the continued epidural injections every 3 months and the use of Mobic.

The employer sent a letter asking the employee to return to work full duty. The employee refused to return to full duty indicating he had not been released to do so by his treating physician. The employer issued another letter advising the employee that Dr. Jone’s report indicated he could return to work full duty. The employee did return to work full duty.

The employee started to get epidural steroid injections every month instead of every 3 months. Each time an injection was given, the employee was off work from Friday through Monday. This lasted for just a few weeks. The adjuster contacted the doctor and advised that they would only authorize injections every three months in accordance with the IME from Jones.

Over the next 6 months, Dr. Meds was able to taper off the claimant’s treatment including office visits, epidurals and the Mobic and he was discharged from care. The adjuster paid all outstanding bills. Shortly thereafter, the employee settled his third party claim and the employer received a check in the amount of $15,000.00 due to the subrogation lien. The adjuster closed the file.

In total, the employer paid: $ 11,090.36 in indemnity benefits $ 1,500.00 for the IME $ 33,250 medical benefits $45,8400.36 total paid $15,000.00 total recovered for the subrogation lien $30,840.36 net paid

ISSUES Light duty was not initially available for the employee. The employer had to send two letters to the employee to return to work full duty. The adjuster was proactive in assessing claimant’s need for treatment.

Case 3: Great Results The claim involves a 45 year old male custodian who alleged he slipped and fell on ice in the building parking lot at 6:30 AM. The employees are told where to park in the lot; the is leased and the employer is not responsible for maintaining the lot.   The employee’s normal start time is 8:00 AM. He had arrived at work early on the date of injury due to the weather conditions. He is a very dedicated employee and felt it would be better to arrive at work early and just wait in the employee lounge until his shift started. However on his way into the building, he slipped and fell on ice in the parking lot.

The employee immediately reported the injury to his supervisor, Joe Smith. The employee stated he had gotten out of his vehicle and had taken several steps when he slipped and fell on the snow and ice covered parking lot. He stated that he had some immediate discomfort and pain in his lower back.

The supervisor had the employee complete an Employee Incident Report immediately which was provided to the HR representative, Candy Jones. Candy met with the injured employee and gathered some additional information from him. The employee was directed to go to First Start Occupational Health who is the authorized provider for the employer. The injured employee did not feel comfortable driving himself so he was taken by Joe Smith.

The claimant was seen by Dr. Evans at First Start Occupational Health The claimant was seen by Dr. Evans at First Start Occupational Health. Dr. Evans had the employee complete a workers’ compensation questionnaire which included a detailed medical history and . , performed a physical examination and x-rays of the lumbar spine. The doctor diagnosed the employee with an acute lumbosacral sprain/strain. He ordered two medications, Flexeril and Norco, for the pain and inflammation. He advised the employee to rest for two days and released him to return to work with restrictions of no lifting greater than 10 lbs. and no bending, squatting or crawling on a frequent basis. The employee was told to follow up in two weeks’ time.

Candy Jones immediately filed the claim with their third party administrator. The TPA received the claim and made contact with Candy. She confirmed that the injured worker is a 20 year employee, his work history is remarkable with great performance reviews, he is known to be punctual and sets a good example for his co-workers. This is his first workers’ compensation injury.

Candy also confirmed they lease the employee parking lot from HAJ Property Company and HAJ is responsible for maintaining the lot when the weather conditions are bad. She believes on this particular morning, it may have been snowing for a while and there may have been a couple of inches of snow on the lot. She will have to check the contract to see what the parameters are for plowing, salting, etc. A subrogation letter will be sent to the employee to put him on notice of the employer’s right to recovery should he pursue a third-party suit.

Candy indicated that they would be able to accommodate the claimant’s light duty restrictions until his next follow up visit. While they did not have an existing job to offer to the employee, they were willing to create a position within his physical capabilities. Therefore he returned to work after his two days off, per Dr. Evan’s instruction.   The TPA followed up and confirmed that the claimant was back to work light duty and that he was back to his pre-injury wages. Therefore no lost time/indemnity benefits would be paid on this claim since the employer was able to accommodate the restrictions.

The employee had his two week follow up visit with Dr. Evans The employee had his two week follow up visit with Dr. Evans. The employee indicated that he was feeling much better but still had some mild pain. Dr. Evans advised him to continue with two more week of light duty and then if he felt better, he could return to his regular duty job. He did not need to see the employee back unless there was a problem. The employee was in agreement with this plan. The employee worked two more weeks of light duty and advised his employer that he was basically pain free and was able to return back to his regular job, which he did.

The claimant did not pursue a third party claim against the owner of the property. Therefore there was no subrogation recovery. As a result of the employer doing all the right things in this case and having a good employee with a positive track record, the total amount paid on this claim was: In total, the employer paid: $450 in medical benefits

ISSUES Good, motivated employee Light duty available Physician panel in place Immediate report of the injury by employee and employer