The Good, The Bad and The Ugly*

With Apologies to Clint Eastwood*

Agenda

• Introductions• Claim Scenario• Red Flags• Claim Scenario – Bad to Ugly• Claim Scenario – Good

Agenda

• Introductions• Claim Scenario – same for all 3 examples• Red Flags• Claim Scenario – Bad to Ugly• Claim Scenario – Good

Introductions

• Shannon Fellin, Esq., Marshall Dennehey• Angela Tennis, Director of Insurance, PennPRIME

Agenda

• Introductions• Claim Scenario• Red Flags• Claim Scenario – Bad to Ugly• Claim Scenario – Good

Claim Scenario

• Claimant is 45 year old male custodian who alleged he slipped and fell on ice in the parking lot at 6:30 a.m.

• Parking lot is leased and the employer is not responsible for maintaining the lot. • Employee’s normal start time is 8:00 a.m.• He arrived at work early. • Claim reported alleged injury to his supervisor.

• Claimant is 45 year old male custodian who alleged he slipped and fell on ice in the parking lot at 6:30 a.m.

• Parking lot is leased and the employer is not responsible for maintaining the lot. • Employee’s normal start time is 8:00 a.m.• He arrived at work early. • Claim reported alleged injury to his supervisor.

Agenda

• Introductions• Claim Scenario – same for all 3 examples• Red Flags• Claim Scenario – Bad to Ugly• Claim Scenario – Good

Do you see any potential red flags?

Agenda

• Introductions• Claim Scenario• Red Flags• Claim Scenario – Bad to Ugly• Claim Scenario – Good

Claim Scenario-Bad

• Why was employee early? • Was it reported? • Supervisor’s response? • Did he get medical treatment?

First Month’s Treatment - Bad

• Panel provider? • Early diagnostics?• Narcotics?

First Month TreatmentOffice visit $66.02MRI – radiologist $450.00MRI – facility fee $958.83Morphine Sulfate $1,821.50Actiq lozenges $11,135.00Trigger point injections $264.50Physical therapy 5 x/week $3,811.39

Total $18,507.24

• Claim petitions filed• 20 days to file answer• Delay in reporting

• Short term employment• Leave time exhausted• Discipline issues

• Legal impact of late answer – Yellow Freight motion• Treating doctor and diagnosis• Opinion of permanently disabled

• Expenses of independent medical evaluation (IME)• Additional litigation if employee doesn’t show up for IME• Requires transportation or mileage reimbursement

• At IME opinion • Full recovery from work injury• Restrictions due to pre-existing degenerative condition

• Length of litigation – interlocutory order versus final order• Additional costs• Credibility of medical experts

• Average weekly wage and compensation rate• Penalties and attorney fees

• Rumors of employee activity?• Surveillance?

• Social media activity check• Video of activities• Other employment – possible fraud?

• Employee Verification Forms• IME to determine ability to work

Claim Scenario – Ugly

• Negative IME doctor opinion

• No light duty• Earning power assessment

• Timing of a Notice of Ability to Return to Work• More litigation

• Expert evidence• Employee defenses

Job opening with current employer

• Settlement• Subrogation

Bad – Ugly $ 31,638.60 in indemnity benefits$ 5,872.00 for the penalty$ 9,000.00 for the claimant attorney fees$ 8,300.00 for defense counsel fees$ 6,500.00 for IMEs$ 900.00 to transport the claimant to the IMEs$ 5,000.00 for the labor market survey$307,991.85 medical benefits$105,000.00 for the settlement$480,202.45 total paid and no recovery for the subrogation.

Issues• All potential claims need to immediately be reported to the Insurance

Carrier or TPA, whether or not the employer believes the claim to becompensable.

• The use of Panels allows for better control of claims from the outset.• If a petition is filed, immediately notify the Insurance Carrier 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)• If the employer has a specific job vacancy that the employee is capable

of performing, the employer must offer such job to the employeebefore having a labor market survey performed.

• Issues regarding potential recoveries from third-party suits need to befully addressed.

• Improper initial investigations can lead to benefits being paid on claimsthat otherwise would have been denied. In some cases, paymentscould continue for 4 years or more.

Agenda

• Introductions• Claim Scenario – same for all 3 examples• Red Flags• Claim Scenario – Bad to Ugly• Claim Scenario – Good

Claim Scenario

• Claimant is 45 year old male custodian who alleged he slipped and fell on ice in the parking lot at 6:30 a.m.

• Parking lot is leased and the employer is not responsible for maintaining the lot.

• Employee’s normal start time is 8:00 a.m.• He arrived at work early. • Claim reported alleged injury to his supervisor.

Claim Scenario-Good

• Why was employee early? • Was it reported? • Supervisor’s response? • Did he get medical treatment?

First Month’s Treatment – Good

• Panel provider? • Early diagnostics?• Narcotics?

• Prompt reporting from HR to TPA• TPA Investigation

• Confirmed employee parking lot is leased• Checked weather conditions• Conditions of premises• Notice to employee of subrogation

• Light duty job made available to accommodate temporary restrictions• Employee returns to light duty• No loss in pay

• Follow up treatment with panel provider• Continued light duty for 2 weeks then regular duty• Claim limited to 4 weeks of light duty

• Employer did all the right things• 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