Never Avoid Your Gut Instinct In Work Comp Claims Handling

From time to time I like to share a file I reviewed on this blog.  Not only to point out the good but also the bad.  Most of the time these claims have various red flags, and they seem quite obvious that the claim was not compensable.  Or on the opposite side the claim was very direct, very compensable, and ended up being very high exposure due to normal factors.  Generally it is nothing new to the typical person involved in everyday claim activity.



Always Question Everything – Even The Sure Bet


Even now and then you see a claim that threw a curveball.  The reason why I like to share these types of claims is to remind you that any claim is capable of a surprise.  It serves as a good reminder that every claim deserves and requires an adjuster that pays attention, doesn’t give up, and stays proactive.  The key is to always question everything—even the sure bet.  Chances are your questions will receive normal answers, and the claim will go on to resolution just as you expected it would.  But every now and then, you will hit upon the right question that explodes a claim right open.



Claim Starts Off Fairly Generic


The following is a brief summary of an actual claim.  The name will be changed, and I will not expose the carrier, employer, adjuster, or anything else that is identifiable but remember this is an actual claim.


The claim starts off generic enough:  A worker at a metal shop was adjusting a machine with a pipe and huge Allen wrench, and when pulling down on the adjustment piece with this pipe he felt a pop in his shoulder.  He reported the claim promptly, and was sent for treatment.


This worker is a 10-year employee, and a good one.  At the time of injury he was in his late 30s.  Nothing came up on the ISO background sweep for prior insurance activity.  The adjuster took his recorded statement and it was very normal.  The claimant gave a consistent background of the injury, his treatment, and so on.  He started off in physical therapy, and placed in light duty.  The injury took place in March.




After First Month No Improvement


After 3-4 weeks of physical therapy, he failed to improve.  An MRI was ordered.  It showed nothing really acute and no rotator cuff tearing.  It did show a chondral defect, and some continued inflammation.  The treating orthopedic doctor opined that the mechanism of injury was consistent with the MRI results, given that an axial load was placed on the shoulder and this chondral injury was the “pop” the employee felt at the time of injury.


The doctor recommended continued therapy, and a series of cortisone injections to try to calm the inflammation.  An IME was completed with a respected local shoulder specialist and supported the treating doctor’s recommendations.  The adjuster approved this treatment and it commenced.


It was around this time that the adjuster began to get a little suspicious.  Here we have a guy a couple months deep into this injury, with little improvement.  But, he was still working light duty, he was compliant with treatment, and his attendance was perfect for everything.  But, the adjuster assigned some surveillance anyway just to be sure.  The surveillance came back with some footage of the claimant running some errands with his kids when not working.  Nothing out of the ordinary.  He was not using the injured arm, and he was not doing anything that he should not have been.




9 Months Later No Improvement – Something Can’t Be Right


Fast forward to early September.  Here we are 9 months post injury for a chondral issue in the injured shoulder.  No rotator cuff tears, no other real degenerative issues other than normal wear and tear.  He remains on restrictions, with little overall improvement since the injury happened.  In fact the treating doctor now states that the shoulder is “frozen” which gave way to a diagnosis of adhesive capsulitis.  This is the diagnosis that most adjusters fear.  A frozen shoulder always is a big deal, with a lot of future treatment ahead and likely a surgical issue that will be the next recommendation.


Something just can’t be right.  The adjuster and nurse case manager bring up their concerns to the doctor.  The treater said that the frozen shoulder is due to the fact that the worker had limited mobility for months, and that nothing seems to solve this chondral issue.  They tried therapy, injections, and nothing seemed to get him on the path to resolution.  It is consistent with the mechanism of injury, and everything seems to add up very clearly to the doctor.




Surveillance Is Tried, And Tried Again


The adjuster still is just not buying it.  Something else has to be going on.  Surveillance is tried again, with the same result: nothing.  The adjuster tried different days, weekend days, holidays, all with no result of the employee doing anything incriminating.


This is where most adjusters may give in.  After all, the doctor only wanted to do a Manipulation under Anesthesia, start aggressive therapy, and the doc actually gave a positive prognosis for full recovery.  The adjuster did due diligence on investigation, and struck out.  Claimant attendance was perfect at work and at therapy, and he did everything that the adjuster had him do.




Case Is Blown Open


Here is the difference: the adjuster did not avoid that gut instinct.  Something kept bugging the adjuster, and it just wouldn’t go away.  Rather than give up on surveillance after about 7 or 8 failed days’ worth, this adjuster tried something new—surveillance through the night.  And not just at night, but full 24-hour onsite surveillance.  Would this yield a different result?


Indeed it would.  Turns out this claimant would work his shift at his employer, and then go home.  Surprise to all, he left his house again around 1am and went to another metal shop a few towns away.  He worked there from 2am to about 6am, then would leave and head right to his job at the first employer where the claim was filed.  This claimant never mentioned a second job, and nobody knew he was working it.  The adjuster then went to the second employer and met the employee in the parking lot, where I imagine an interesting conversation took place.




Nothing Can Replace Gut Instinct


This lead to a dispute on the file, and the case was currently heading towards litigation upon my review.  The point to remember here is to not give up and to continually question everything.  Here, the adjuster had tried everything, and 6 months later they were finally able to bust the claim open.  Even on a seemingly compensable case such as this, there is no value or training that can replace gut instinct.




Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  Contact:


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