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Coverage Test > Chapter 9 Intro to Causality Claims > Flashcards

Chapter 9 Intro to Causality Claims Flashcards

1
Q

Factors leading to injury from an accident

A

-Vehicle design
-Speed
- Road Design
- Road Environment
- Driver skill
- Driver impairment
Driver Behavior

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2
Q

2 Types of Injuries

A

Traumatic
Chronic

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3
Q

Traumatic

A

injury is brought on by a recent event occurring outside of the body

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4
Q

Chronic

A

one that develops slowly over a longer period of time

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5
Q

Neck

A

sprain, strain, fracture, herniated disc injury, thoracic spine injury, fractured vertebrae, lumbar radiculopathy, and lumbar spine injury.

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6
Q

Whiplash

A

ligaments, tendons, and muscles. It includes thehyper-extension(movement of head backwards)andhyper-flexion(movement of the head forward)of the cervical region. There may be a torn muscle or bleeding if the whiplash is severe. It can take from several days to months to heal. The suggested treatment is rest and pain relievers plus immobilization of the area.

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7
Q

Strain

A

This is defined as an overexertion of a muscle beyond its normal capacity. There may be some inflammation. The recommended treatment for a strain consists of moist heat and rest. The length of disability depends on the degree of the strain and age of the person.(stretch)

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8
Q

Sprain

A

stretching or tearing of ligaments(tough bands of tissue that connect to the bone and support the joints in the correct position while allowing movement) or tendons that(connect muscle to the bone). The recommended treatment for a sprain is ice and rest. The disability period depends on the severity of the sprain. For a partial tear, the disability period is less than a complete tear.
(tear)

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9
Q

Spinal Injuries

A

The spine consists of many different components such as the vertebrae or bone and the soft gelatinous discs which exist in between. Trauma to the spine may cause fractures to the bone or injury to the disc –such as disc bulging or disc herniation. Further, the nerves that travel to the upper and lower extremities channel through the spine area – such that an injury to an area of the spine may also cause corresponding injury to that part of the body where the nerves extend.

		Breakfast at 7
		Lunch at 12
		Dinner at 5
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10
Q

Limb Injuries

A

Arms and legs are susceptible to fractured bones and lacerations in a car accident. In the case of lacerations, the closure of the wound may require sutures by a doctor. If broken bones are involved, the injured person may have to go weeks or months in a cast. In some cases, physical therapy may be needed to regain full use of an injured limb.

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11
Q

Brain Injuries

A

One type of injury seen in car accidents is a closed head injury, which can range from amild concussionto atraumatic brain injury(TBI) where the person has to re-learn to walk and talk. Car accidents can cause different types of brain injuries, includingbruising(contusions)orbleeding(hemorrhage). Death is a possible result in more extreme situations.

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12
Q

Psychological Injuries

A

Injuries caused by car accidents aren’t limited to just the physical. After a car accident involving severe injuries or loss of life, drivers and passengers may suffer short or long-term psychological injuries such asemotional distress.

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13
Q

Facial Injuries

A

Injuries to the face can be caused by impact with a number of items in the vehicle including the steering wheel, dashboard, airbag, windshield, side window, car seats or shattered glass. These injuries range in severity from scrapes and bruises to lacerations and fractures.

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14
Q

Shoulder Pain

A

Shoulder injuries are commonly claimed by drivers and passengers in rear-end accidents. Common shoulder injuries claimed include dislocation, separation, rotator cuff, frozen shoulder and fracture.

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15
Q

Knee Pain

A

Common knee injuries claimed due to an auto accident are torn meniscus, Anterior Cruciate Ligament (ACL) and/or Medial Collateral Ligament (MCL) tear.

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16
Q

Seat Belt Injuries

A

In accidents where enough force is placed on the vehicle occupant, injuries involving the seatbelt may include bruising or occasionally fractured ribs.

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17
Q

Air Bag Injuries

A

While airbags save lives and prevent injury in serious car accidents, they can also cause injuries. The deployment of an air bag can be harmful to vehicle occupant depending on the nature of the accident, their height, age, and the point of impact. Eye injury and facial burns are possible injuries due to air bag deployment.

18
Q

Causal Relationship

A

When investigating an injury claim, it is important to find out who is at fault, whether there were any injuriesANDwhether those injuries were caused by the accident made the subject of the claim. (Remember: a.) DUTY, b.) BREACH OF DUTY, c.) CAUSATION and d.) DAMAGES)Did the injury take place before or after the accident as opposed to during? Was there a separate intervening cause? Is there liability (fault) from other parties as it relates to causation of the injury alleged?

19
Q

Exacerbation or Aggravation

A

The term exacerbation is used when the treating physician is referring to an injury which preceded the accident but which the accident may have made temporarily worse for some period of time.
Factors to consider when looking at pre-existing injuries include claimant age, overall physical condition, weight and activity level, and compliance with medical recommendations. The physician may include these terms in their medical reports, but the claim representative should carefully review the past medical documentation and the records of the current treatment to try and distinguish between the condition prior to the current accident, and the claimant’s current condition.

20
Q

Mechanism of Injury

A

Considering the forces present in the incident, by evaluation of the forces applied to the body. This includes understanding of body motions in response to forces and body tissue tolerance to these applied motions and forces.

21
Q

Low Impact Accidents

A

In other situations, the claim representative may be required to make a determination of whether an injury is probably (not possible) as a result of an impact which has been established to have taken place at a very low speed (zero to ten miles per hour). Such accidents usually cause minimal vehicle damage and very small degrees of force required to cause injuries thus requiring a heightened analysis to confirm the causal relationship and review the biomechanical forces upon the occupants of the vehicles involved. In such cases multiple detailed photographs of the vehicles involved are most useful and should be sought as soon as possible in the investigation.

22
Q

The Medical Investigation

A

These areas should focus on:
○ The alleged injuries
○ The nature and extent of treatment,
including the reasonableness and
necessity of the treatment and
corresponding costs
○ Understanding the injuries’ impact on
the person
○ Determining the permanency of the
injuries
○ Assessing the relationship between the
accident and the injury
The claim representative should attempt to
determine the answers to the following
questions:
○ What is the alleged injury?
○ How did the injury occur?
○ Is there a causal relationship?
○ Did the injury result solely from this
accident?
○ Is the injury complicated by a prior
physical condition?
○ Where and what type of treatment is the
claimant receiving?
○ Is the claim being inflated or built-up by
excessive treatment and charges?
○ What is the disability? Is there
permanency of disfigurement?
○ Is the claimant a “malingerer”?
What are the objective complaints versus the subjective complaints?

23
Q

Medical Authorization

A

Claims rep should explain what a medical authorization form is to the injured party and email or mail it to them. A signed and dated medical authorization from allows the CR to obtain the individual’s medical records relating to the injuries cause by the accident.
*If the claimant has their records electronically they can email them to the CR.

24
Q

Wage Authorization

A

When a person is injured in an auto accident, they are often instructed by the doctor to take time off work in order to aid in the healing process. If this is the case, then the special damages of the injured party would include their claim compensation for the time missed from work. In the consideration of such a lost wage claim, verification must be secured by the claim representative to determine the missed work was legitimate and casually related to the auto accident.
If the injured party is claiming lost wages as a result of the auto accident, the claim representative may send a wage authorization form to the injured party’s employer. The employer will complete and return the form with the days missed, wages lost and expected return to work date. We owe for net pay only. Let’s review a wage authorization form (handout). The wage authorization should also be explained during the first call with the claimant and sent via email or mail.
*We only pay loss wages due to injury.

25
Q

Medical Reports and Records

A

Medical reports and records are the foundation of a medical investigation as they include the information needed for a proper evaluation of the injury. It is through these reports and records the injury allegations are verified.
In order to obtain medical reports and records, which are confidential, the claim representative will need to secure a medical authorization form signed by the claimant. If the claimant is off work due to an injury, a lost wage form should be secured when requesting salary information and verification of time off from their employer. The medical records would also have to justify the need for the claimant to miss work due to their injuries.

26
Q

Interpreting Medical Reports

A

A review of each medical report will ensure the vital information from each report is considered.

ER Records- Report should include the place, date and time of the accident, a brief description of what happened, claimant’s medical history, the complaints, test results, initial diagnosis and recommended treatment.

Physicians Report
It provides specific information on the accident, history, diagnosis, treatment, causal relations, disability and prognosis.

Hospital Records
These records contain the details of a patient’s confinement in the hospital. Includes doctors/nurses’ notes, exams, tests results, intake info and discharge sheets.

27
Q

Common Medical Tests

A

Diagnostic Testing
Physical Exam
Range of Motion
Cervical Range of Motion
Lumbar Range of Motion
X-Rays
Magnetic Resonance Imaging (MRI)
CAT Scan
NCS/EMG- identify nerve damage

28
Q

ESBI- Early Settlement Bodily Injury Considerations

A

· Early Settlement Bodily Injury (ESBI) cases occur during the first 30 to 60 days after a loss is reported where the claims professional and claimant agreed to a full, fair and final settlement of the claimant’s BI claim.

	· Sometimes an injured party simply went to the emergency room or their doctor to get checked out or for minimal treatment because the injuries are admittedly minor. The injured party likely has no plans for future treatment or if they do –it is also minimal with an immediate end date in sight. In these cases, the claim representative (sometimes even the MD adjuster) can attempt to promptly settle the claim. Such claims are referred to as representing “early settlement” opportunities as the injured party is declining ongoing medical care and not seeking the representation of an attorney to further handle their claim.
	
	· There are a number of benefits to consideration for an early BI settlement even given the specialized claim handling format utilized in the NGIC Claims department. The appropriate management of these cases allows for a reduction in claim severity and costs, a greater control of pending claims as well as incoming mail and phone calls

If there is NO injuries alleged, no ESCI offer should be made

29
Q

CLAIMS that Qualify for Early Settlement

A

○ Coverage confirmed and liability determined (using LIQ if eligible)
○ Injured party can be claimant or insured driver or passenger (may be UMBI vs BI)
○ Injured party may be pedestrian
○ No attorney involvement
○ Minor to moderate vehicle impact
○ Inconvenience is not an injury and should not receive an offer
○ If treating actively with a chiropractor, physical therapy, etc. –the case should NOT be considered for ESBI (unless settled on an incurred/open-ended release)

30
Q

INJURIES that Qualify for Early Settlement

A

○ Soft tissue neck and back
○ Minor sprain/strain of other body parts (e.g. wrist or ankle)
○ Bruises, lacerations, abrasions and scrapes
Headache (if it is a residual of the soft tissue)

31
Q

INJURIES that DO NOT Qualify for Early Settlement

A

○ Fractures (arm, leg, ribs, etc)
○ Disc injuries
○ Scarring
Closed head injuries (concussions)

32
Q

Treatment Providers

A

○ Emergency Room
○ Urgent Care
○ Primary Care Physicians
○ Anticipated treatment with provider (e.g. “I’m sore and going to the doctor Tuesday”)

33
Q

Special Damages

A

○ Medical Bills
○ Wages
Prescriptions

34
Q

Determining Settlement Value

A

Consider the following information for general damages value in addition to any medical expenses.
○ Intensity and duration of recovery period (pain and suffering)
○ Were there complaints of injury at the scene
○ Is the injury objective or subjective
○ Injured party’s age/physical condition
○ Impact on lifestyle (should be none or minimal otherwise NOT considered for ESBI)
Aggravated circumstances (e.g. DUI, pregnancy, etc)

35
Q

Settlement Options

A

Once general damages, treatment and specials have been assessed the adjuster will determine settlement value and negotiate a fair and reasonable ESBI settlement with the injured party. There are three settlement options for ESBI, and the adjuster should explain the appropriate option to the claimant.

        Straight ESBI up to $1,000
		§ No special damages to reimburse
		§ Any settlement above $1,000 should be 
                       discussed with manager
		§ If case settles the adjuster will
			□ Open Bodily Injury exposure if it was 
                                 not previously
			□ Put “Full and Final Settlement” on 
                                  check (make sure state allows 
                                  language)

       Medicals Incurred
		§ Injured party has advised they incurred 
                      some bills
		§ Explain “incurred release” allows for 
                          payment of bills incurred
		§ Settle general damages and incurred 
                      medicals
		§ When case settles the adjuster will
			□ Open Bodily injury exposure if it 
                               hasn’t been already
			□ Issue check as final payment
			□ Send Incurred Release with the 
                                  check

       Open-Ended
		§ Injured party has advised they are 
                           planning to go to the doctor
		§ It is not a low impact case
		§ Injuries were indicated at scene
		§ Explain “open ended release” allows for 
                      payment of future bills for related 
                     reasonable and necessary treatment 
                     received up to the agreed number of days 
                      (not to exceed 60 days)
		§ Limit on the amount of bills up to $1,500
			□ Manager approval necessary on bills 
                                in excess of $1,500
		§ Treatment consideration not to exceed 
                    60 days
			□ Manager approval necessary if it is 
                                 to exceed 60 days
		§ Settle general damages and open-ended 
                       medicals
		§ When case settles the adjuster will
			□ Open Bodily Injury exposure if it was 
                               not previously
			□ Issue settlement check as final 
                              payment
			□ Send open ended release with check
		§ Close file and reopen if medical bills are 
                        received
36
Q

Releases

A

Straight ESBI
Release of All Claims (State Specific)
Put “ Full and Final Settlement of Injury Claim” on check

Open Ended Language should include:
Amount of general damages
Agreed dollar limit on medical bills of length of treatment ($1,500 medicals incurred up to 30 days)

Parent and Guardian
Follow rules of jurisdiction

Medicals Incurred language should include:
Amount of general damages
Amount of medical bills of an estimate of the bills incurred prior to date of settlement
37
Q

Documentation

A

File should be properly documented and at a minimum should include a discussion of the following:
* Coverage
* Liability
* Facts of Loss
* Impact Severity
* Injured Party Information
○ Injury description
○ Injury complaints
* Bodily Injury Evaluation
○ Treatment
○ Provider
○ Special Damages
* Settlement Value
* Negotiation
○ Amount of offer
○ Agreed upon settlement amount
* Type of Settlement
○ Straight ESBI
○ Incurred/Open ended
* Additional Notes
○ Including follow-up plan if offer is not accepted immediately
○ Any other pertinent information to the claim

38
Q

Objective Finding

A

( see the injury)

39
Q

Subjective

A

(cannot see the injury)

40
Q

What to do after ISO report comes back

A

Review and write a summary of the report

41
Q

TLO

A

The Last One
Last known phone number
Last known address

Coverage Test (7 decks)

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