The Stakes: A water and sewer pump company was facing a Mod increase due to a single incident. An employee who had just returned from non-work gall bladder surgery suffered a herniation at the incision site while moving materials. It looked like a standard WorkComp claim.
The Investigation: The Advisor brought in an independent Registered Nurse to review the medical facts. They needed to determine if this was a new work injury or a complication of the personal surgery.
The Breakthrough: The nurse’s investigation confirmed the herniation was a direct medical complication of the recent surgery, not a new occupational hazard. The Advisor presented these findings to the carrier, arguing the claim belonged under the employee’s Health Insurance, not Workers’ Comp.
The Result: The carrier agreed and denied the WorkComp claim. The employee received care under the correct policy, and the employer avoided an 8-point Mod hike that would have cost $15,000 over three years.