Narrative Questions

Question 1

Identify FIVE (5) titles used to identify individuals who investigate, assess, and pay bodily injury claims.
(5 marks)

Answer 1

Claims adjuster titles

• claims adjuster
• claims representative
• case manager
• claims examiner
• insurance adjuster

Question 2

Outline the questions an adjuster could ask with respect to coverage when presented with an
automobile claim. (5 marks)

Answer 2

Adjuster’s questions

• Does the policy cover the vehicle involved?
• Did the accident arise out of the ownership,
• use,
• or operation of the automobile?
• Was the automobile used with the consent of the owner?

Question 3

Outline the mechanics for taking written statements from a claimant. (5 marks)

Answer 3

Statement-taking mechanics (Five of the following answers will be acceptable for 5 marks)

• Use a pen.
• Leave no blank spaces—not even margins.
• Do not underline.
• Number each page.
• Mark through any deletions with a single line.
• Have statement giver initial each page and each correction.
• Do not use a date stamp.
• Have the statement giver read it, make any corrections, and sign it.
• Have the signature witnessed.
• Have the statement read back and then signed if given through an interpreter.

Question 4

Briefly describe the movement of the hand. (5 marks)

Answer 4

Movement of the hand
• A total of 35 muscles control the hand.

• Of these, 15 are located in the forearm, thus reducing bulk in the hand.
• The muscles become thin, cord-like tendons at the wrist.
• Muscles in the palm and the palm side of the forearm allow the hand to close.
• Muscles in the forearm cause it to open, and the tendons in these forearm muscles run on the backside of the hand

Question 5

Outline the symptoms of a sprain. (5 marks)

Answer 5

Sprain symptoms
• There is usually severe localized pain around the involved joint and over the point where the
tearing and stretching has occurred.

• Severe swelling will usually take place; inflammation resulting from the injury is caused by fluid moving into the surrounding tissues.
• In addition, small blood vessels are damaged and the escaping blood accumulates under the skin and increases the swelling; discoloration follows as the blood decomposes in the tissue.
• If the knee or ankle is involved, weight bearing will be difficult and painful. Severe sprains to the knee may be more disabling than a fracture.

• In a severe sprain, the ligaments, tendons, capsule, cartilage, and bones that form the joint may
be damaged.

Question 6

Briefly explain how the driver of a vehicle can suffer the flexion-extension injury known as whiplash.
(5 marks)

Answer 6

Explanation of a flexion–extension injury
• The driver of a vehicle is supported to a degree by the seat of that vehicle, but the head and neck
areas are often unsupported.

• If struck from the rear and pushed ahead so that the vehicle rapidly accelerates in a forward
motion, the body will then be naturally thrown backward.

• The braced part of the body will sink back into the seat, but the unsupported neck and head will be whipped backward and then forward again.

• When the head is thrown backward, the supporting muscle structures of the cervical area will be
strained and stretched.

• Concurrently, since the shoulder area is braced, the head is thrown backward and the lumbar
area (the small of the back) is arched and extended, so its musculature may also be affected.
(15 marks)

Question 7

Outline the treatment for dislocation of the bones that form a joint. (5 marks)

Answer 7

1Dislocation treatment
• Proper force or leverage is used to return the bone to its place through the tear.

• Usually the dislocation is repositioned and then immobilized to stay in place with a sling or splint.
• If the dislocation has caused ligament damage, surgery may be needed.
• When a dislocation is not severe, sometimes controlled movement can begin quite early.

• The immobilization period (with a cast or splint) may last for weeks, and medication is usually
prescribed to help with pain management.

Question 8

Compare the TWO (2) major types of fracture: simple and compound. (5 marks)

Answer 8

Comparison simple and compound fractures
Simple fracture

• In a simple or closed fracture, the bone does not pierce the skin, so it is not exposed to the air.

• The bone may be broken in two or more parts.
Compound fracture

• In a compound fracture the bone is exposed to air—that is, the skin is pierced.

• It is classed as compound only when direct communication exists between the body surface and
the fractured bone ends.

• This type of fracture is more prone to infection, and healing is often slow.

Question 9

Briefly describe a myoplastic amputation procedure explaining why it is performed. (5 marks)

Answer 9

Myoplastic amputation procedure

• A myoplastic amputation procedure is often used to remove circulation in the extreme end of the stump to achieve better muscular control.
• This is accomplished by closing the end of the bone with an osteoplastic flap and connecting the muscles to the end of the bone.
• This tends to assist circulation above the site of amputation and to eliminate complications.
• The stump is muscular and warm, the skin is smooth, the tension in the muscles is normal, and the stump itself is rounded and neat.
• This technique is used for initial amputations and as corrective surgery to improve unsatisfactory stumps.

Question 10

Outline the usual treatment for an intervertebral disc injury. (5 marks)

Answer 10

Usual treatment of intervertebral disc injury
• Usually treatment consists of rest, massage, gradual exercise, heat in various forms, bracing,

• and drugs to relieve pain and relax muscles.
• Herniated discs have at times been treated with traction.
• Surgery is sometimes recommended when all other treatment methods have been exhausted.
• Usually only the nucleus pulposus is removed in disc surgery, also known as a discectomy.

Question 11

Briefly explain why an adjuster is interested in the difference between vital and non-vital teeth.
(5 marks)

Answer 11

Reasons for adjuster’s interest

• A vital tooth has internal strength because the pulp and dentinal tissue are alive.
• A non-vital tooth has had its nerves and blood vessels (pulp) destroyed or removed.
• A non-vital tooth becomes dried out,
• has a brittle structure,
• and is prone to fracture with slight or minimal trauma.

Question 12

Compare paraplegia and quadriplegia. (5 marks)

Answer 12

Comparison of paraplegia and quadriplegia

• Paraplegia is the paralysis of both legs and the lower part of the body caused by a spinal cord injury.
• If the spinal cord is severed in the thoracic or lumbar sections of the spine, paraplegia results.
• Quadriplegia is the paralysis of arms, legs, and most of the body trunk caused by a spinal cord injury.
• It is caused when the spinal cord is severed within the cervical area of the spinal column.
• The level of functionality the patient has will depend on where exactly the damage occurs on the spinal cord.

Question 13

Differentiate between the heart conditions of dysrhythmia and arrhythmia. Briefly explain how these
conditions are treated. (5 marks)

Answer 13

Differentiate heart conditions and explain treatment
Heart conditions

• A disturbance or abnormality of the heart’s electrical conduction system is known as dysrhythmia.
• Absence of an effective heart beat is known as arrhythmia.

Treatments
• Treatment is dependent on whether or not the affected person is stable or unstable.

• Treatment could include physical manoeuvres, medication,
• electricity conversion, or electro- or cryocautery.

Question 14

Describe the process by which the lungs work. (5 marks)

Answer 14

Process of lungs working

• Lungs are involved in external respiration—that is, ventilation.
• External respiration is the process of inspiration (inhalation),
• in which oxygen is received into the bloodstream via the lungs,
• and expiration (exhalation),
• where carbon dioxide and vapour are expelled from the body.

Question 15

Describe the location and purpose of the kidneys. (5 marks)

Answer 15

Location and purpose of kidneys Location
• The two kidneys lie in the back portion of the abdominal cavity

• on the outside of the peritoneum wall.
• They are located on each side of the spine just above the small of the back.

Purpose

• They filter waste products from the blood
• and maintain the body’s acid-alkaline balance.

Question 16

Briefly outline the categories that provide the diagnosis of somatic symptom disorder (SSD). (5 marks)

Answer 16

• Requires one or more somatic symptoms that are distressing
• or result in significant disruption of daily life with predominant pain.

• Requires excessive thoughts or feelings or behaviours related to the somatic symptoms as
manifested by at least one of the following:

o Disproportionate and persistent thoughts about the seriousness of one’s symptoms;

o Persistently high anxiety level about health or symptoms; or

o Excessive time and energy devoted to these symptoms or health concerns.

• Requires somatic symptoms to last at least six months.

Question 17

Objective and subjective injuries compared

Answer 17

Objective
• Objective injuries are defined as those that are supported by medical evidence and are verifiable
indications of injury,
• including spasms, atrophy, identifiable fractures, bleeding, reduced range of motion, and so on.
• The findings are measurable and reproducible.
Subjective
• Subjective injuries are defined as those that are not supported by any objective findings
• and are diagnosed based on the claimant’s complaints.

Question 18

Permanent and temporary disability contrasted

Answer 18

Permanent disability
• A permanent disability will persist for the duration of the claimant’s life.

• It can be completely incapacitating

• or it might be a minor permanent disability that interferes only slightly with normal job duties and
leisure activities.

Temporary disability
• A temporary disability will last only a limited period of time.

• The injury is expected to fully heal, and it is only during the healing time that the person is
disabled.

Question 19

Briefly describe the positive effects of an adjuster maintaining contact with a claimant and her family.
(5 marks)

Answer 19

Positive effects of adjuster’s contact

• A claimant gains much peace of mind when the adjuster explains the insurance contract, benefits
payable, and period of indemnity.

• The mere fact that someone has taken an interest in the case helps to build rapport and improve
morale.

• The concern of a patient and family about the mounting bills and expenses during the disability
period can impede the recovery of the patient.

• Adjusters should consider including family members when discussing the rehabilitation program.

• Caring family members can help motivate the claimant, and success may be limited without a
family support system (the family that does not understand the rehabilitation process can
inadvertently cause further harm to the patient).

Question 20

Outline how an adjuster can contain costs when managing a claim. (5 marks)

Answer 20

Managing claims costs

• In some cases, prices for rehabilitation services can be negotiated.
• It is also necessary to make appropriate choices with respect to services purchased.

• Consultants and specialists usually charge on an hourly basis for professional services and a
lesser hourly rate for non-professional services.

• It is not effective to enrol the claimant in every program available.
• Consideration must be given to what can be accomplished with the cash available.

Question 21

Outline typical barriers to recovery during rehabilitation.

Answer 21

Barriers to recovery
• Attitudes, emotions, and external factors can affect the success of any rehabilitation.

• There may be a possibility that the patient’s symptoms have not led to the proper diagnosis.

• A minimal brain injury can sometimes be overlooked but may cause serious complications for the
claimant.

• Physical barriers may make it impossible for the person with the disability to be considered for the
job.

• Discrimination and negative attitudes can also be a barrier to the success of the rehabilitation of a
person with a disability.

Question 22

Briefly describe the information contained in medical records known as clinical notes.
(5 marks)

Answer 22

Information in clinical notes

• Clinical notes are prepared by doctors and other health care providers to record medically
relevant information on patients they treat.

• The course of treatment for injuries and illnesses is documented in this way.

• These records are dated and include the patient’s complaints, examination results, details of
medical referrals to other specialists, test results, and the treating physician’s observations.

• They also include the doctor’s correspondence to other medical professionals and to advocates
or lawyers representing the claimant.

• They also contain reports from surgeons and X-ray technicians such as radiologists.

Question 23

Briefly explain why it is important to differentiate between the use of the words “possible” and
“probable” in medical reports. (5 marks)

Answer 23

Why important to differentiate between “possible” and “probable”

• In assessing damages, a court will pay little if any attention to the “possible” consequences of an
injury.

• However, a consequence established as “probable” will merit definite consideration in the assessment of damages.
• Medical evidence that the patient will possibly suffer from a particular condition at a later date as a consequence of the injury is of no value in assessing damages.
• If, however, “probably” is substituted for “possibly,” there is a value.
• Often the doctor can state the degree of probability in percentage terms, which a court will find helpful.

Question 24

Outline why an adjuster would want to obtain an independent medical report (IME).
(5 marks)

Answer 24

Reasons for an independent medical report (IME)

• The claimant’s doctor has not provided adequate or timely medical information upon which a claim can be evaluated.
• The claimant’s complaints and ongoing disability extend beyond the normal acceptable rate of
recovery.
• Complaints are grossly disproportionate to the injury.
• Conflicting or ambiguous medical information needs clarification.
• There is a need for evidence from a specialist.

Question 25

Briefly explain burden of proof. (5 marks)

Answer 25

Explanation of burden of proof

• Burden of proof is the standard by which a claim must be proven to prevail.
• It is typically borne by one party or another.
• The burden of proof generally rests with the claimant (the person making the claim) to prove negligence on the part of a responsible party and to claim damages.

• The onus to prove negligence can shift to the defendant because of a statute or the applicability
of a legal doctrine.

• Whether the claim succeeds or not depends on the evidence available.

Question 26

Outline the factors the courts have suggested be considered when assessing non-pecuniary damages.
(5 marks)

Answer 26

Factors considered when assessing non-pecuniary damages

• Type of injury suffered and attendant loss of amenities.
• Pain and suffering.
• Length of time over which the suffering and loss of amenities will take place.
• The plaintiff’s ability to appreciate the injury, including the pain and suffering, and loss of amenities.
• How the plaintiff’s life expectancy has been altered.

Question 27

Briefly describe legal protection insurance and explain how it can affect a claimant’s willingness to proceed to trial. (5 marks)

Answer 27

Legal protection insurance description and effect on willingness to go to trial

• This insurance means the claimant will not be out of pocket for costs if he or she is awarded an amount less than the formal offer of the defendant, up to the policy limits.
• For some plaintiffs this will give them the confidence they need to go forward to trial on what might otherwise be a questionable claim.
• Policy limits are not funded unless there is an adverse decision; this will prevent the damage award being reduced by the costs owing if the claimant loses at trial.
• These policies can be enhanced to include disbursements.
• There is a suggestion that this type of insurance puts the plaintiff on equal footing with insurers, who have deep pockets; but not really the case because insurers are bound to fund claims within the policy limits of their insureds where there are serious liability issues and injuries caused by the policyholder’s actions.