We received an email from a former case manager who shares with us a candidate [case manager] for the worst claim handling she ever saw. This claim also turned up in a workers compensation claim file audit. A case manager was handling claims for a statewide private hospital chain. And oh Boy, all of the following mistakes were on one workcover file…rendering an injured nurse just about 100% impaired and with a shattered life.
One of the worst workcover claim handling we heard of
Mistake #1. Handling the claim before insurance coverage was verified
The perceived lack of insurance coverage wasn’t addressed again until the hospital executive director contacted the case manager about 4 months later. By then over $65,000 had NOT been paid on medical and indemnity by the case manager (and insurer). There was clear coverage but the hospital chain was in an estoppel situation, so the case manager continued to deny to cover the legit workcover claim.
Mistake #2. The second case manager not reading the first case manager’s file notes
Best Practices for a workcover case manager includes making contact with the employer, the injured worker and the medical provider within 24 hours after receiving the claim. The insurer had overloaded its workcover cse managers with around 250 cases each. The second case manager on the file never even saw the claim during the first three months it had been assigned!
Mistake #3. Not reviewing the file when it was assigned to her (the new case manager)
Mistake #4. No timely contacts with the involved parties were made
Mistake #5. No investigation of the workcover claim
Since the second case manager never contacted the insured (hospital), the injured worker or the medical provider/treater, there was no investigation into the claim. The employer’s report of injury (the claim) stated that “the employee (a nurse) hurt his lower back when he tried to move a large patient out of a chair.”
File note entries read “Received medical bill” or “Not Paid medical bill” with the name of the medical provider and the bill amount. One medical report summarized in the file notes stated, “employee continues to work with his low back pain”. Three months into the claim a medical report stated “will need to do bilateral [back] surgery for slipped disc.”
Mistake#6. Not comparing medical reports with the reported injury on the claim.
The employee was an obese nurse with diabetes – two factors that can bring on or exacerbate back injury according to the glorified clerk (case manager) -WTF! Even though the claim was reported as a clear, evidenced back injury, the case manager questioned the need for surgery and treatment and stated in the file “that the nurse was fat and must surely have been suffering from pre-existing back problems”!
Mistake #7. Failure to separate a covered injury from other medical conditions of the employee.
Mistake #8. Lack of medical knowledge that being “fat” is not
always injury related.
Mistake #9. Medical termination based on whether the back injury was work related.
Mistake #10. No on-going contacts with the injured worker and the employer.
The first contact with the injured worker eventually occurred over six months into the claim when the injured worker called the case manager inquiring about when she would be paid for her weekly wages, as she was off work due to the severe back pain. She also asked whether her surgery had been approved. The case manager did not follow up on the weekly pay and surgery request question and got another phone call from the injured worker. The first contact with the employer occurred almost seven months into the claim when the case manager asked the employer for a wage /salary statement.
Mistake #11. Not obtaining the wage statement from the employer when it was first noted the employee was going to need back surgery.
The case manager “forgot” about following up on weekly pay entitlement and request for surgery. As the case manager had not been in contact with the injured worker or the employer, the weekly pay checks just kept being on hold.
Approval for surgery was finally given 10 months into the claim and after the CEO had called the insurer (having himself received complaint letters from the injured nurse and his medical treaters). It took just about 11 months before the injured nurse received her first weekly pay!
The thick case manager also did not know the injured worker would not return to work until receiving medical reports stating that the injured nurse was at maximum medical improvement on her back injury and had been given a 15% impairment rating. The employee missed out on an extra 12 weeks of weekly payments after she was found to be unable to return to work, because the case manager found in the “book” that the nurse should have recovered and be back at work within 12 weeks post surgery. The case manager stated in the claim file notes that the underpayment of benefits would be added to the permanent impairment lumpsum settlement. However, it was never done.
Mistake #12.Not making any effort to get the injured worker back to work earlier or to return to work on light duty, or to offer a vocational assessment and retraining.
The injured nurse had (eventually) only been back to work (in the most unsuitable duties of physical nursing, under pressure and threats of the case manager who would “cut off her benefits if she did not comply with a return to work plan) for two months when the case manager contacted her about an “overpayment of weekly pay” and settlement of the lumpsum claim. The injured nurse advised the case manager that her back still hurt and that the doctor had ordered a new MRI of the low back. The nurse was found to have a herniated disc at L4-L5 and a partially herniated disc at L5-S1. The doctor scheduled further surgery for the injured nurse.
Mistake #13. Not having inquired about the lack of medical treatment on the low back for almost a year.
The pathetic case manager, finally paying attention, refused to approve the surgery until an independent medical evaluation (IME) could be completed. The IME confirmed the need for the surgery. After the surgery, the injured nurse was off work for another seven months before the doctor placed her at “maximum medical improvement” with a 25% permanent impairment rating.
Mistake #14. Not making any effort to get the injured worker back to work on light duty or suitable duty, and not engaging a rehab service provider to assist the nurse with RTW
The case manager eventually contacted the injured worker with an offer to settle both of her permanent impairment ratings based on her being 25% disabled. The injured nurse, rightly, argued that she should be considered 100% disabled as she was not able to go back to her job as a nurse. The case manager refused to consider the claimant as having permanent total disability. A week later, the case manager received a letter of representation from the injured worker’s new lawyer, who claimed the employee was much more impaired and that a Medical Panel would need to assess the nurse. The case manager refused to refer the injured worker to a medical panel for permanent impairment rating!!! The lawyer requested a court hearing. The court reviewed all the medical records and agreed with the injured worker and his lawyer and dismissed the case manager/ insurer’s defense lawyer. The employee’s attorney appealed. The injured worker was assessed by a Medical Panel and was found to be 40% permanently impaired and that he could not return to work as a nurse. The insurer eventually paid the 40% rating lumspum.
Worsening of Condition
Another year later the injured worker’s lawyer contacted the claims office, but the second case manager was no longer with the insurer. A third case manager on the claim learned that the lawyer filed a request for workcover (and the agent) to consider a “worsening of condition.”
It was now obvious that the present injury was not a new claim, but the exacerbation of an old claim. However, the case manager refused but then accepted a the injury as a new claim. So the current insurer was stuck paying for the claim although it was an exacerbation of the original injury. Talking about starting all over again!
Back to the Medical
The injured worker’s disk fusion surgery had failed. The treating doctor recommended another surgery. The third case manager was too inexperienced to be handling this type of claim. The case manager asked her supervisor what to do. The supervisor said to get another IME – a well known biased one!. The IME stated that the fusion had partially failed, but absolutely did not recommend another surgery.
The injured worker’s lawyer gave the third, simple minded case manager a sad tale of how much pain the injured nurse was in, that his marriage was falling apart due to her pain and he was desperate to have the surgery.The case manager and her supervisor eventually agreed to the surgery, knowing now that the lawyer would refer the matter to a Medical Panel or a Court of Law. It took another 6 months for having the approval in writing!
Mistake #15. Allowing ignorant case managers ‘uneducated medical opinions” instead of medical facts to make the determination on how to proceed on a claim
The case manager should have approved the additional surgery much sooner!Following the second surgery, the treating doctor had given the employee a total 75% Permanent impairment rating based on the two back surgeries and psychological injuries sustained during his “ordeal”. The insurer arranged yet another IME and got a similar rating of 65% total permanent impairment. The case was eventually settled out of court and the injured nurse was awarded 75% total body impairment, pain and suffering. The nurse, now half paralysed and suffering incontinence (because of the massive delays for surgery) was also found not to be able to return to any work for the foreseeable future.
[Post predicated and manually entered on behalf of WCV]