Members of the claim management team are called upon to make important decisions at the inception of a claim. One of these decisions includes the investigation of idiopathic injuries and making determinations regarding primary liability. While this may take more time, failure to understand the mechanism of injury can result in extra time and money being spent.
Idiopathic Injuries Result From Unknown Origins
Simply put, idiopathic injuries are those that result from unknown origins that more likely than not are the result of workplace exposure, or related to a workplace injury. In its basic form, it is an injury resulting from a condition or disease an individual has that has nothing to do with their place of employment and is not easily explained.
A common example of an idiopathic injury includes an employee walking down a hallway free of imperfection – suddenly, their knee gives out. Was it work-related? Is it compensable under workers’ compensation? These types of injuries present several challenges for all interested stakeholders in the workers’ compensation system.
- Employee: Proving up their case – receiving compensation for their work injury;
- Employer: Preserving evidence that will be used in determining primary liability, and zealous defense of the workers’ compensation claim; and
- Insurer: Diligent and proper claim investigation, and if necessary, making a legally defensible determination regarding liability.
Investigating Idiopathic Work Injuries
Investigating idiopathic injuries starts with a timely and accurate report of the work injury. For members of the claim management team, the following needs to occur to make the right decisions:
- Encourage employers to have an open line of communication with their workforce. Make sure injuries are reported in a timely manner can help preserve evidence;
- Accurate reporting is essential. Do not guess the weights of various objects or distances involved. Make sure everything is documented correctly; and
- Preserve all evidence. This includes taking a photograph of conditions as they excited at the time of the incident in case they could change. Examples of this include a hallway that has carpeting, uneven surfaces, slippery surfaces that might be covered in ice; and stairwells.
Determine Exact Mechanism of Injury
The devil is in the details – attention to details is required. It is important to determine the exact alleged mechanism of injury. Document the best you can in terms of movements and motions made by the employee at the time of the injury. When you are able, make a contemptuous recording to “lockdown” someone’s version of events. Pre-existing conditions are also important to uncover. Other important factors to consider include:
- Did an injury occur because of a work activity?
- Was the employee performing work activity consistent with the claimed injury?
- If there was, in fact, a work injury, what body parts are involved? Defining an injury by ICD-10 codes may also be important given the reporting requirements for Medicare and Medicaid coordination of benefit issues.
- How long did the employee engage in the work activity for it to result in a work injury? Was it a substantial contributing factor in the disability and/or need for medical care and treatment/disability?
- If not a specific incident-type injury, when did the injury culminate?
It is essential to provide this information to an independent medical examiner. Questions regarding these issues may involve a medical director, nurse case manager, or someone with an advanced understanding of medicine.
Other idiopathic injuries in workers’ compensation can include workplace exposure to dusts, allergens, asbestos, and idiopathic pulmonary fibrosis. These claims can be difficult to defend as some jurisdictions have a statutory presumption, albeit rebuttable, which puts insured on the defensive – literally. These complex cases require the use of experts to successfully defend.
Idiopathic injuries create a series of challenges for members of the claim management team. Defense of these claims involves proactive actions from the defense interests to preserve evidence, determine with accuracy the circumstances surrounding the events leading up to the injury, and the injury itself. Failure to take these important steps can increase program costs and lead to excessive litigation.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is founder & lead trainer of Amaxx Workers’ Comp Training Center.
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