The claim: Employee reported to work limping and within the following week reported an injury lifting a pan that weighed less than four pounds. The claim has paid almost $80,000 in benefits arising from a back injury. The problem: it didn't happen on the job. Or, in the worst-case scenario, was a very minor aggravation of a pre-existing injury that would have lasted a week or two and resolved.
The analysis: Where did the employer miss the proverbial 'boat'? There was suspicion that the employee was hurt off the job and a diligent investigation rounded up all the supervisors and found mainly hearsay that the employee has a private business at a farmer's market and other high level activity. Not really enough for the adjuster to justify a full denial of the claim. Almost a year later, it was discovered, at an unrelated meeting, that there was one person (not interviewed in the original investigation) who was not a supervisor but a co-worker who saw the allegedly injured employee come into work limping and complaining of a hurt back from his 'other job'.
The lessons: Hindsight being 20/20, two lessons:
Teresa A. Long is Director of Injury Management Strategies for the Institute of WorkComp Professionals, which trains insurance agents to help employers reduce Workers' Compensation expenses and of which we are a member.Teresa was claims manager for 14 years for Walt Disney World and later was Regional Operations Manager for Alternative Service Concepts.