Friday, July 1, 2011

The Dreaded Soft Tissue Issue Part II

As we have talked about in previous blogs the soft tissue injury is often the most difficult to treat and determine severity because at some point physical symptoms begin to fade. This is the reason that the soft tissue injury is the injury of choice for the "professional claimant".Whether or not the injury occurred is not the issue it is typically the severity and duration that often baffles doctors and frustrates adjusters.

Take for example a claimant that Nationwide SIU currently has under surveillance. This "claimant" has had three workers comp claims of duration in the past 10 years. But it did not stop there she is currently under suit with a business for a slip and fall injury. The subject claims a right ankle injury as well as a left shoulder. According to the claimant she was walking down some stairs in which she claims a employee may have spilled some water and or ice and she slipped, fell and braced with the left shoulder and twisted the right ankle. After several months turned into several years of symptoms and pain the only conclusion the doctors could come to is possible rsd/crps. RSD/CRPS is known as complex regional pain syndrome and is characterized by persistent pain that does not go away with time and in some instances increases as time passes. The brain, spinal cord and nerve receptors have issues communicating with each other causing additional localized and regional pain.

Typically this injury is very debilitating and when sufferers of this disease are inflicted with pain it is severe at best unbearable at most. The only physical symptoms being tissue swelling and in severe cases can have pathological changes in bone and skin. There is no test to positively determine if the subject has the disease and is simply determined by the physical symptoms and the degree of pain the subject claims. This is where our "claimant" takes advantage of the system incurring thousands of dollars of medical expenses and trying to get a suit settled for a large payday. 

One good way to determine the severity as well as the validity of the claim is through surveillance. If it is determined that there is a good chance that the claim is exaggerated or even fraudulent, doing several days of surveillance at different times can answer some questions about where the adjuster and insurance company stands. In this particular case study the first few days of surveillance provided evidence that the subject was exaggerating her claim and there were several instances of the subject acting outside of her stated restrictions and being inconsistent with her actions. The subject used a crutch, mostly for show, while walking but switched it from arm to arm to accommodate her activity rather than her injury. The subject was also seen standing on one leg without using any other support, and getting in an out of vehicles without hesitation.

The key to this particular case is not only the frequency of her inconsistencies but also the duration of acting this way. Making sure to get several different days of surveillance showing the exaggerated injury to disprove the "good day, bad day" argument is critical. Making sure the subject was consistent in their acting outside of restrictions shows that they are exaggerating the claim.

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