When medical evidence does not add up in a liability claim


A Sedgwick liability nurse was asked to analyze the records of a claim involving a 52-year-old man whose car was struck when our client’s truck driver fell asleep at the wheel, overturning his rig and causing damage to several cars.  Liability was not in question, but there was substantial dispute over the damages. The initial plaintiff demand of $750,000, included $140,000 in medical specials and defense counsel assessed the verdict value of $350,000-700,000 based on the severity of the accident and claimed injuries.

The plaintiff alleged that when the air bag in his car deployed, he lost consciousness and sustained traumatic brain injury, accelerating a pre-existing hearing loss and causing vestibular damage requiring surgical intervention with cochlear implants. A treating physician found that the plaintiff had a congenital disorder that caused his underlying hearing problem and suggested that his type of disorder might have placed him at greater risk for worsening in the presence of head trauma. In addition:

  • The liability nurse reviewer found nothing in the medical records to support either loss of consciousness or evidence of head trauma at the time of the accident.
  • Several months after the accident, the plaintiff reported that he was losing his balance as a result of pain in his legs. The nurse identified that the plaintiff’s orthopedic problems were pre-existing, stemming from a prior injury and pointed out that four of his pain medications were associated with dizziness, gait instability, lack of sensation in the feet, and diminished coordination. The records also contained a statement from the plaintiff to his physician indicating that he had lost his job as a result of falling asleep at work due to sedation.  Once he reduced his use of pain medications his balance improved.
  • The primary cost of the plaintiff’s claim was related to the accelerated hearing loss, but the nurse found that prior to the accident he had a lifetime of hearing loss and was already relying on lip reading and a hearing aid for communication.
  • The liability nurse was able to assist the adjuster in disputing the medical specials, citing the lack of medical indicators for the cochlear implants for his balance problems.
  • The liability nurse identified records not previously identified by the plaintiff attorney and made recommendations for types of experts that might be required should the case proceed.

By the time of mediation, the demand was in excess of one million dollars. The adjuster saved the cost of outside referral and used the nurse’s information about lack of causal links between the treatment provided and the claimed neurological, auditory and vestibular injuries to negotiate a favorable settlement.

The case settled at mediation for $285,000.  Cost to the claim file for the liability nurse review was only $440.

Liability nurse consultants are highly experienced clinicians and consultants with experience in a variety of specialty areas.  Additionally, the nurses are also licensed claims adjusters who provide great value in understanding the needs of other claims adjusters in providing details for the claim file.  Needless to say, their services are highly cost competitive especially compared to the very expensive demands of liability claims.

While we know that the liability nurse consultant may not  have  a dramatic impact on every case, their approach provides claims adjusters with a medically trained resource to assist in the analysis and evaluation of injuries allegedly sustained by injured parties—creating good outcomes and cost savings.

Please feel free to share your thoughts and questions with us; the Sedgwick liability nurse consultant team is available to help meet the needs of your organization.

April Clemens, Business Relationship Manager, Specialty Operations, Sedgwick

Diana Shick, RN Consultant Team Lead, Liability Nurse Program, Sedgwick

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