Correct medical diagnosis keeps employer from feeling the pain of a Mod increase


The insured is a water and sewer pump company and employs 27, locally. There are additional employees in two other states as well.


An employee had undergone gall bladder surgery in late January. He has released back to work full duty (without restrictions) three weeks later. On his second day back to work, this employee was moving some cross ties and herniated his healing surgical incision, necessitating further medical and surgical interventions.


Certified WorkComp Advisors (CWCA) began investigating this claim and determined further assessment was necessary. An independent Registered Nurse with experience in occupational injuries was engaged and began an investigation. After reviewing the circumstances of this injury and speaking with the employer to get specifics about the employee’s recent abdominal surgery, the nurse concluded that the herniation was a result of complications from the surgery.


The independent nurse alerted the carrier to this determination and the claim was denied under Workers’ Comp. The carrier agreed that this herniation was a complication of and was directly related to the recent abdominal surgery. The claim was instead submitted to the employee’s health insurance plan for coverage.


This claim was closed in less than three weeks, saving the employer the cost of medical care and potential future wages. Disability guidelines report that a typical uncomplicated incisional hernia costs an average of $21,102 ($10,001 in indemnity and $11,101 in medical expenses). Had this claim been accepted under Workers’ Compensation, it would have increased the employer’s Experience Mod eight points, or a total of approximately $15,000 over three years (based upon the rate & payrolls remaining constant over the three year period).


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