Application Question

Question 1

Application Question
Study 1 - Investigating Bodily Injury Claims

1. Vivian Payne is an 84-year-old woman living in a semi-retirement nursing home. Vivian suffers from
   tremors and since she quite frequently loses her balance, she opted to go into a care facility that could
   monitor her and check on her regularly.
   Vivian’s daughter Sarah lives 50 kilometers away. She visits her frequently and speaks to her on the
   phone regularly. Sarah got a call from an attendant at the facility that her mother fell and was in hospital.
   When Sarah visited her mom in the hospital, the right side of her face was bruised and her speech was
   slurred. She was awake, but disoriented. Because of her age, and the nature of her injuries, the doctors
   advised that Vivian’s recovery would be long and difficult.

a. How would an investigator obtain a statement from the patient, if she was in such poor shape? (5
marks)

b. What steps would an investigator take to ensure that the facts presented are correct? (5 marks)
c. How would the facts be verified? (5 marks)

Answer 1

Answers:

a. Statement-taking with a claimant who is in care
• Adjuster needs to check with medical personnel in charge to get permission to speak to the patient.

• Adjuster needs to ensure that the claimant/patient is physically able,
• not under the influence of drugs,
• and of sound mind.
• Make the patient comfortable by having a family member present when being questioned.

b. Steps investigator should take to ensure facts are correct

• Adjuster needs to gather information and take statements for the claimant/patient.

• Obtain permission from potential witnesses first, then take statements from other witness present
(attendants/staff/care-givers/other residents).

• If a third party has hired a lawyer, obtain permission from the lawyer to question or interview the claimant
• Explore other (authorized) sources of information, such as medical reports from doctors and hospitals
• Independent adjusters need to follow the same rules or protocols, and get written permission from the claimant to access health records/care records.

c. Verify facts

• Adjuster will need to have knowledge of certain types of injuries to determine the settlement amount.

• Adjuster would have to follow up with the claimant/patient and conduct an activities check to see
if there are long-term lasting symptoms.

• Adjuster would have to look at any evidence or information regarding the circumstances of the
fall, for example:
• Type of footwear was the claimant wearing
• Wet floors or surface
• Obstacles or obstructions in the way of where claimant was walking

Question 2

Application Question

1. Frida works for the parks department in her local municipality. While she is pruning trees and clearing
   underbrush in a wilderness-style park, she tumbles down a slope and sustains bruises, cuts, and some
   significant lacerations to her arms and legs. She is taken to a local clinic for medical assistance.

Since the slope has been made more unstable by recent heavy rains and soil erosion, the municipality
has their adjuster assess Frida’s injuries and any possibility of a negligence claim.

a. Based on the facts given, briefly describe the traumatic skin injuries Frida suffers. (5 marks)

b. Outline the treatment the clinic gives Frida for the lacerations to her arms and legs. Explain why this is
necessary. (5 marks)

c. Two weeks after her fall, Frida visits the clinic again because some of her bruises have increased in
size. The doctor suspects that the bruising is more serious than originally assessed and that
hematomas have formed. Briefly explain what hematoma is and how it will be treated. (5 marks)

Answer 2

Answers:

a. Traumatic skin injuries
• Frida suffers abrasions when the skin is denuded by rubbing and scraping, caused by her body hitting the ground as she tumbled.

• She suffers contusions—injuries where the skin is not broken—that is, bruises.
• There may be no surface skin damage in these areas, but there is damage to underlying tissues that result in ruptured blood vessels.

• Frida suffers lacerations—tears of the flesh, usually having an irregular, jagged, and shredded
appearance, such as where she hit the ground or undergrowth.

• Lacerations are usually described by how big they are and how deep the wound is and are
measured in centimetres. Often there is severe contusion about the wound.

b. Treatment for lacerations and explanation
Treatment

• Frida’s lacerations may need to be cleansed to remove dirt, contamination, and badly damaged
tissue. (When this is surgically necessary the process is called debridement.)

Why necessary
• Lacerations do not bleed as freely as clean incisions or cuts.

• Blood vessels are shredded and, as a result, clotting in these vessels occurs rapidly, checking the
flow of blood.

• Free bleeding tends to wash out the wound, carrying contamination out of the tissue in the damaged area.
• In lacerated wounds this contamination is often not washed out, and infection can occur quickly.

c. Explanation of hematoma and its treatment

Explanation
• The damage to Frida’s underlying tissues was already assessed as resulting in ruptured blood vessels—this has led to the formation of a hematoma, which is pooled blood from damaged blood vessels under the skin’s surface.

• Frida’s hematoma has not disappeared and continues to increase in size; this usually means that
there is continued bleeding within the tissues.
Treatment

• It may be necessary to incise the wound to drain the blood (often a needle is used to perform this function).
• Incise is a procedure to drain the blood from a wound made by making a surgical cut to the affected area.

• Ligation—or the tying or bonding of blood vessels—may be necessary to control the bleeding.
(15 marks)

Question 3

Study 3 - Skeletal System
Application Question

1. While Anthony is riding his new mountain bike downhill in Mountainview Park, the bike wobbles and

Anthony falls off, landing heavily on his right arm. The post-injury medical report shows that Anthony is
diagnosed with a fracture of the radius and ulna in the right arm and a probable wrist sprain.

a. Briefly describe the radius and ulna. Explain how the fracture occurs. (5 marks)
b. Briefly explain what a sprain is and how Anthony’s wrist sprain is diagnosed. (5 marks)

c. The medical report also indicates the presence of synovitis. Briefly describe this condition and explain
how it will be treated. (5 marks)

Answer 3

Answers:

a. Description of radius and ulna and explanation of fracture

Description
• The arm is made up of three bones the humerus and the ulna and the radius.

• The ulna and the radius are known as the forearm.

• The radius is attached to the lower end of the humerus and extends to the hand in line with the
thumb.

• The ulna is also attached to the lower end of the humerus and extends to the hand.

Explanation of fracture

• When an outstretched hand is used to break a fall, the force, if great enough, will be transmitted
to the forearm. When Anthony falls off his bicycle he likely extends his arm and hand trying to
break his fall.

b. Diagnosis of the sprain

Sprain
• Joint injuries are often associated with sprains.
• Sprains involve the partial tearing of ligaments.
• The common areas of injury are the ankle, knee, wrist, and hand (in this case, the wrist).

• Damage to the soft structures can be more painful than fractures, due in part to the generous
supply of sensory nerves surrounding the structure.

Diagnosis
• X-rays are essential for accurate diagnosis of wrist injuries because of the many small bones
within the wrist and the way in which they articulate.

c. Synovitis and treatment

Synovitis
• Synovitis is an inflammation of the synovial membrane which lines the capsule of a joint.
• It is frequently encountered with sprains and joint injuries.

• Synovitis appears as a swelling and is characterized by generalized discomfort.

Treatment
• It can be relieved by aspiration of the fluid that has collected or an injection of cortisone.

• There are various types of this problem, but often accident-related injuries are resolved with rest.
(15 marks)

Question 4

Study 4 - Spine, Head, and Nervous System
Application Question

1. Patrick, a ten-year-old boy, falls 2 m (6 ft) out of an old tree he is climbing in the city park. He hits his
   head on the concrete walkway below. Patrick’s friend tries to help him but soon realizes that Patrick is
   only barely conscious and unable to move.
   The medical staff at the hospital says that Patrick has fractured his skull and there is a possibility of brain
   injury. Since Patrick’s parents put in a claim against the city, the city’s adjuster attends at the hospital.

a. Briefly outline what the adjuster would want to know about Patrick’s fractured skull. Explain why the
adjuster would want to know this. (5 marks)

b. Outline the symptoms the adjuster would expect Patrick to exhibit if he has a brain injury. (5 marks)

c. How would the adjuster expect Patrick’s doctors to assess whether Patrick has a brain injury? (5
marks)

Answer 4

Answers:

a. Types of fracture and why the adjuster would want to know

What
• Which of the four basic types of fractures to the skull has Patrick suffered (basal, linear,
depressed, or compound)?

Why
• Because the severity of skull fracture is often gauged by the amount of injury to the brain and the
nerves that enter and leave the brain.

• Basal and linear fractures usually resolve themselves without difficulty.
• Depressed fractures are serious and can result in permanent impairment.
• Compound fractures may result in permanent disability.

b. Symptoms of a brain injury
• Loss of consciousness, temporary amnesia, a state of confusion, dizziness, and vomiting.

• Any changes in Patrick’s cognitive, behavioural, and physical skills since he was barely conscious
when first seen by medical staff.

• Cognitive disabilities such as disorientation, memory loss, inability to make decisions, and loss of
concentration.

• Behaviour and personality symptoms such as apathy, impulsiveness, aggressiveness, anxiety,
depression, indecision, or indifference.
• Physical symptoms such as poor balance, poor coordination, fatigue, headaches, and dizziness.

c. Doctors’ assessment
• The brain emits electrical waves, which can be measured by an instrument called an
electroencephalogram (EEG).

• It is a long and involved process that begins with assessing the severity of the original trauma and
analyzing the ensuing progression of recovery.

• To judge the severity of a brain injury, doctors use the Glasgow Coma Scale.
• Patients answer questions on a standardized test and their responses are recorded.

• Post-traumatic amnesia, confusion, and poor orientation are also factors to consider.
(15 marks)

Question 5

Study 5 - Heart, Lungs, and Other Organs
Application Question

1. Lucy is stopped at a busy intersection in town during the mid-day rush when her car is hit from behind
   by an SUV. The impact throws Lucy forward into her steering wheel and causes bruising of her chest and
   arms. When the ambulance arrives, Lucy refuses medical treatment, insisting she is just shaken up and
   bruised. Later that night Lucy is rushed to the hospital because she is having trouble breathing.

a. Outline the probable cause or causes of Lucy’s breathing problems. (5 marks)

b. Lucy’s doctors are concerned she may be going into shock. Briefly explain what shock is and why it is
a concern. (5 marks)

c. Briefly explain the treatment for shock. What other main problem is likely to be present as a result of
Lucy going into shock? (5 marks)

Answer 5

Answers:

a. Causes of breathing problems
• A blow to the chest may cause injury to one or both lungs.
• Blood vessels are susceptible to traumatic injury.
• Lucy may be hemorrhaging internally.
• Hemorrhaging is bleeding into a body cavity from a perforated organ or blood vessel.
• Or blood may have leaked into the thoracic cavity causing a hemothorax (collection of blood in
the pleural cavity).
b. Explanation and why concern about shock

Explanation
• Shock is the immediate effect of massive blood loss
• It is a complication that can arise if the lungs are lacerated or collapsed.

Concern
• Shock is a leading cause of death among trauma victims.
• Basically, the heart must beat faster to circulate the same amount of blood to the tissues of the
body (the amount of blood has been reduced because of volume loss).
• If the blood loss is severe enough, the heart will not be able to keep up with the demand and will
fail.
c. Shock: treatment and other problem

Question 6

Study 6 - Psychological Disorders and Disability
Application Question

1. Roberta was a line cook working the morning shift in a deli when she was involved in a serious kitchen
   accident with hot oil and fire. Roberta was badly burned and required skin grafts to her arms and upper
   body.

Nine months later, after extensive medical treatment, Roberta is certified medically fit to return to work.
Roberta insists she cannot return because she constantly relives the accident and is terrified of the
prospect of a reoccurrence of the circumstances that led to her injury. Her doctor refers her to a
psychologist.

The psychologist determines that Roberta is having spontaneous memories of her traumatic workplace
injury with flashbacks and associated distress. Based on the diagnostic clusters in the Diagnostic and
Statistical Manual of Mental Disorders V (DSM-V), the psychologist has diagnosed Roberta with PTSD.

a. According to the DSM-V, what symptoms would the psychologist have identified for the diagnosis? (5
marks)

b. Outline the treatment the adjuster would expect Roberta’s doctor to recommend. (5 marks)

c. After investigation, the adjuster suspects Roberta may be malingering. Outline typical reasons for
Roberta to be malingering. (5 marks)

Answer 6

Answers:

a. Symptoms diagnosed
• According to the DSM-V, PTSD is triggered when a person is exposed or threatened with death,
serious injury, or sexual violation.

• The disturbance causes clinically significant distress or impairment in the individual’s capacity to
work.

• Roberta is re-experiencing the traumatic event.

• The DSM-V emphasizes the “flight” aspect associated with PTSD (Roberta is refusing to go to
work).

• The DSM-V requires that a disturbance continue for more than a month, so the psychologist
would have to determine how long Roberta has been experiencing this.

b. Expected recommended treatment

• Immediate crisis counselling.

• This should include supportive counselling that encourages the injured person (Roberta) to move
forward.

• Medication is used to alleviate anxiety and impulsivity and to improve sleep.

• Non-medication treatment, such as supportive psychotherapy, can include debriefing, which
attempts to normalize emotional responses.

• Psychotherapy assists with reducing stressors, thus improving a person’s ability to cope.

c. Reasons for malingering

• She could have psychosocial problems that prolong her report of illness.

• She may be enjoying the powerful support network offered by rehabilitation programs, as well as
the disability payments that substitute for paycheques.

• The delay to return to work often results because claimants were dissatisfied with work before the
accident.

• She may be magnifying her symptoms.
• She may be failing to report her recovery.

Question 7

Study 7 - Rehabilitation
Application Question

1. Frank, a construction worker, is badly injured when a building wall collapses on top of him. He sustains
   injuries to his back and hips. After reconstructive surgery, which includes fusing several vertebrae in his
   back, Frank’s family doctor refers him to a rehabilitation program. Frank is now seeing a physiotherapist,
   vocational specialist, and a psychologist.

a. Briefly explain how the physiotherapist can help Frank. (5 marks)
b. Briefly describe the services the vocational specialist provides. (5 marks)
c. Briefly explain why Frank needs to see a psychologist. (5 marks)

Answer 7

Answers:

a. Explanation of physiotherapist’s help
• Physiotherapists diagnose, assess, and treat conditions that limit physical and functional
independence.
• An individual treatment regime is planned to promote healing and normal function to the injured
person (Frank).
• Physiotherapy is used to reduce pain and improve range of motion.
• Passive techniques are used, such as applying heat, electrical stimulation, ultrasound, and laser.
• Active techniques, such as teaching gentle stretching movements, and other treatments that
combine the two techniques are also used.

b. Vocational specialist’s services
• The vocational expert predicts the likely work personality and probable maximum potential of the
person (how Frank will fare in the workplace).
• The specialist can provide Frank with emotional and psychological support,
• and work with the current employer and the employee to devise a plan to lighten the workload,
• or otherwise modify duties to enable Frank to return to work sooner.
• If Frank cannot return to the same job he had before the accident the vocational consultant can
identify transferable skills that can be used to identify other job duties.

c. Why psychologist needed
• Psychologists can help patients with many problems,
• including coping with chronic pain and fatigue and emotional problems caused by the trauma of
an accident.
• The psychological effects of an accident may require counselling or therapy.
• Frank may be suffering from the effects of post-traumatic stress disorder.
• He may have complaints associated with a disturbance in memory function that may be a
consequence of anxiety, depression, or overmedication.

Question 8

Study 8 - Medical Records and Reports
Application Question

1. Six months ago, George Brown, a self-employed heritage cabinet maker, was injured in a three-car
   automobile accident. His vehicle was sideswiped by a van entering the travel lane and pushed into oncoming traffic where he was hit by a third vehicle. As a result of the accident, George suffered back injuries and spinal damage that affected the fine motor control in his hands. He has been unable to continue his work as he cannot sit or stand for extended periods due to pain in his back, and he cannot properly control the tools he uses for the fine detail work on his products.

As part of the claim process, the bodily injury adjuster for the defendant has received a copy of the
medical-legal report prepared for George’s legal counsel.

a. Briefly describe what a medical-legal report is and explain how it is used. (5 marks)

b. Outline what types of information the adjuster analyzing this report will find with respect to George’s
injuries and their effects on his ability to work.
(5 marks)

c. Outline what the report would include with respect to the doctor’s prognosis of George’s condition. (5
marks)

Answer 8

Answers:

a. Description and use of a medical-legal report
• Medical-legal reports are prepared by the treating doctor using clinical notes in a patient’s file to provide evidence of the effects of an injury.

• Specialists and other consulting doctors prepare reports when patients are referred to them by attending doctors; their report(s) should address any specific issues raised by the referring doctor.
• When prepared by medical experts hired by legal counsel for the claimant (which it was in this case), the medical expert is asked to provide an opinion with respect to the claimant’s diagnosis, causation of symptoms, treatment needs, and prognosis.
• Adjusters request these reports to evaluate a claim.

• They are also used by lawyers.
b. Types of information on injury effects and ability to work (Five of the following answers will be acceptable for 5 marks)

• The adjuster will expect to find information on what the impairment is and how it prevents George from participating in his employment.
• George is complaining that he cannot work because he cannot sit or stand for extended periods because of his back injuries, and he cannot do the fine detail work required in his products because nerve damage has caused the loss of fine motor skills.
• Questions the adjuster should consider include the following:

o Is this a total disability or is George capable of doing some other work?

o Is the disability reasonable considering the impairment and the George’s job duties?

o What was the extent and duration of pain and suffering?

o George’s pain should be graded according to severity—severe, moderate, or mild.

o The length of time the pain lasted and any other neurological symptoms should be mentioned.

o Prescribed drugs and therapy should be identified and rated on their effectiveness in the report.

o Any other recommendations made to the patient should be mentioned such as what other
medical treatment was prescribed.

Question 9

Study 9 - Evaluation, Negotiation, and Settlement
Application Question

1. Lucille Matias is injured during a supervised hike with Venture Out Hiking Association at its resort location. Venture Out turns Lucille’s claim over to its insurer,
   Recreation Insurance Limited. After Recreation Insurance’s investigation and the claim negotiation, the parties have still to resolve the issues of liability (Lucille signed a waiver releasing Venture Out from all liability) and quantum. Lucille’s lawyer progresses to litigation.

After the examination for discovery, Recreation Insurance‘s claim examiner proposes that the parties attempt to resolve the claim through an alternative dispute resolution (ADR) mechanism.

Lucille and her lawyer are somewhat reluctant to proceed with ADR until the claim examiner assures
them that he was considering mediation, not arbitration.
a. Compare the ADR methods of mediation and arbitration, explaining the difference between them.
(5 marks)

b. Outline why Recreation Insurance would want to attempt to resolve the claim through an ADR
mechanism rather than continuing through litigation.
(5 marks)

c. Briefly describe Recreation Insurance’s claim examiner’s role should Lucille’s claim go through the
courts. (5 marks)

Answer 9

Answers:

a. Difference between mediation and arbitration (Five of the following answers will be acceptable for 5
marks, with at least 2 points from each section)

Mediation

• Mediation does not bind the participants to a result.

• Usually involves an impartial third person who intervenes in the dispute to help the parties come
to a solution themselves.

• Mediators seek to improve the communication between the parties, ensuring that each party
understands how the other sees the obstacles to settlement.

• Mediators do not make decisions; their role is to keep the parties working together to come to agreement on settlement.

Arbitration

• Arbitration is a process whereby the dispute is submitted to one or more impartial parties for a
final and binding decision.

• Neutral persons are chosen by the parties in dispute to determine their rights and/or obligations.
• The parties agree in advance to abide by the arbitrament.
• Each party is heard, issues are examined, and a settlement is developed.
• The settlement can be final and binding.

b. Why ADR rather than litigation

• The court system has encouraged the development of many alternative dispute resolution options.
• Litigation is an expensive and time-consuming process.
• Insurers are recognizing that some claims may be resolved with speed and thrift using an alternative dispute resolution (ADR) mechanism.
• Parties reaching a solution using mediation tend to be more satisfied with the end result.

• The purpose of arranging ADR is to have matters decided earlier rather than wait to be called to
trial in areas where the courts are backed up with volumes of cases

c. Examiner’s role when claim goes to court

• Usually the examiner refers the complete file to a lawyer.
• The examiner continues to manage the file to keep expenses down and ultimately to resolve the case.
• The lawyer will be given specific instructions on how the file should progress and the role the lawyer should play.
• Sometimes lawyers may be asked to prepare the matter for trial based on the supporting evidence obtained; it is not unusual for the lawyer and the examiner to consult on the case.
• Examiners may find it useful to continue monitoring a case that has been referred to a lawyer to develop an understanding and appreciation of civil proceedings.