Correct medical diagnosis
keeps employer from feeling the pain of a mod increase
Insured
The insured is a water and sewer pump company and employs 27, locally. There
are additional employees in two other states as well.
Situation
An employee had undergone gall bladder surgery in late January. He was released
back to work full duty (without restrictions) three weeks later. On his
second day back to work, this employee was moving some cross ties and herniated
his healing surgical incision, necessitating further medical and surgical
interventions.
Assessment
Certified WorkComp Advisors (CWCA) began investigating this claim and determined
further assessment was necessary. An independent Registered Nurse with experience
in occupational injuries was engaged and began an investigation. After reviewing
the circumstances of this injury and speaking with the employer to get specifics
about the employee’s recent abdominal surgery, the nurse concluded
that the herniation was a result of complications from the surgery.
Solution
The independent nurse alerted the carrier to this determination and the
claim was denied under Workers’ Comp. The carrier agreed that this
herniation was a complication of and was directly related to the recent
abdominal surgery. The claim was instead submitted to the employee’s
health insurance plan for coverage.
Result
This claim was closed in less than three weeks, saving the employer the
cost of medical care and potential future wages. Disability guidelines report
that a typical uncomplicated incisional hernia costs an average of $21,102
($10,001 in indemnity and $11,101 in medical expenses). Had this claim been
accepted under Workers’ Compensation, it would have increased the
employer’s Experience Mod eight points, or a total of approximately
$15,000 over three years (based upon the rate & payrolls remaining constant
over the three year period). |