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RS claims analyst closes another questionable injury claim

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Here’s a great example of how Retail Services’ team of claims adjusters looks out for Retro members.

Senior claims analyst Michele Whinery closed a case where a worker filed a claim for a shoulder strain after pulling a pallet, which the employer did not question.

Once the claim was allowed, diagnosis and treatment began for the shoulder. In a short period of time the claim became more complex with additional conditions such as joint arthritis. Surgery that was promptly performed did not match up to the original diagnosis. By this time, the case reserves were set to more than $295,400.00 due to the complexity of the case!

Whinery discovered an ankle surgery had been performed and that a bacterial sepsis or staph infection occurred in both a foot and shoulder. As our analyst looked further, the worker claimed his foot injury happened at the same time as his original shoulder injury, for which there were no witnesses. He also claimed no prior treatment to his ankle or shoulder, which was not supported by discovered facts.

At Whinery’s urging, prior medical records were requested and an Independent Medical Exam (IME) with specialists was finally allowed after the Office of the Medical Director (OMD) reviewed Whinery’s concerns that she outlined in a convincing argument. As suspected, this case was due to pre-existing conditions. This enabled Whinery to begin protesting all the worker’s time loss benefits paid while waiting for the IME. Additional chart notes revealed ankle surgery 10 years prior and that the worker had failed to have the stabilizing hardware removed, which was now causing the sepsis.

After the IME Report findings were complete, Labor & Industries issued multiple subsequent segregation orders (separating conditions from the claim) that denied sepsis, shoulder septic arthritis, shoulder acromial joint arthritis, septic ankle arthritis, post-traumatic ankle arthritis and an MSSA bacterial infection. An MSSA infection commonly is called a staph infection, which is treatable with antibiotics. This left only the shoulder strain as the lone treatable diagnosis on the claim.

This resulted in an overpayment due to the unrelated conditions in the amount of $10,085.42 to the worker and reversal of bills in the amount of $20,798.58 and claim closure. If not for Whinery’s good work, this claim would have cost the employer in higher insurance rates and the Retro pool $750,000 or more. Whinery’s experience and diligence paid off and resulted in a big win for the employer and Retro members.

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