Short-Term Considerations That Can Impact a Catastrophic Claim

Previous injuries, surgeries, and existing health conditions can delay an injured worker’s recovery and play a significant role in catastrophic cases. An injured worker’s occupation or education may seem insignificant when recovering from multiple amputations or a traumatic brain injury (TBI). However, if even the slightest consideration can affect an outcome by a small percentage, it is worth exploring and could completely change the direction of care.

“The claims team must use every resource at their disposal to determine the unknowns that could prevent the best possible outcome,” said Jessica Unser, Senior Claims Manager at Safety National. “Do what makes sense. If it can impact the claim and potential outcome of an injured worker by even 1%, it’s worthy of further investigation.”

Many factors can complicate an injured worker’s condition and prevent an optimal outcome. Here are a few that need to be investigated when handling a catastrophic claim.

Complicating Factors or Injuries

Complicating factors can include other traumas, like kidney failure, or surgeries that still need to occur while the catastrophic injury is being treated. This can also include previous injuries or disabilities like amputations, back injuries, fusions or even hardware. Failure to acknowledge these factors can all drastically delay recovery time.

Effective Resources

Which resources can be the most beneficial to the injured worker and the claim? Centers of Excellence can provide extended care for severely injured workers and should be considered in the recovery process. Medical bill review is also an incredibly effective resource for cost reduction on a claim.

Psych and Social Dynamics

Often psychiatric history and social dynamics are unknown at the beginning of a claim but are undoubtedly worth exploring. Family history, living conditions and social dynamics can all influence an injured worker’s recovery. Formal attendant care may be necessary if a spouse or family member cannot take on the demand of round-the-clock care.

Comorbidities

Diabetes, high blood pressure, previous drug or opioid addiction, and psychiatric issues must be reviewed and documented when assessing the injured worker’s care and the reserves on file. Comorbidities can cause serious complications when treating other injuries and can prolong treatment.

Occupation

An injured worker’s occupation plays a large part in their rehabilitation time. Certain professions require considerably more rehab than others, based on the physicality of the job requirements. For example, when assessing their ability to return to work, a firefighter who needs to climb ladders will need more time in recovery than an employee returning to a desk job.

Severity of the Injury

Is the injury high-risk, like a TBI with comorbidities, or is it a relatively low-risk injury with few complicating factors? Higher risk will typically mean a longer recovery and rehabilitation time, with higher associated costs.

Education

To get the injured worker back to work, their current level of education needs to be assessed. Vocational rehabilitation may be necessary if the individual works a physical job that they cannot return to due to severe disabilities. This process can enable a person with functional, psychological, developmental or cognitive disabilities to overcome barriers in returning to work.

Age

Survival and recovery rate are incredibly dependent on age. An 18-year-old surviving a high-risk injury will have a vastly different outcome than a 70-year-old experiencing the same injury.