Many in our industry are familiar with the case management role of nurses in the workers’ compensation arena, where they support injured and ill employees and oversee the treatment and recovery process. But, did you know that nurses can also play a critical role in the resolution of liability claims that involve illness or bodily injury? Known as liability nurse consultants, they use their medical knowledge to help clients and claims professionals decipher medical records and terms, assess treatment plans, mitigate damages, and facilitate timely and appropriate resolutions.
Supporting fair settlements
Our nurse consultants are uniquely skilled in evaluating the medical facts associated with general liability, bodily injury and auto claims. The kinds of claims we review may include a retail customer sustaining an in-store fall, a consumer suffering food poisoning from a contaminated product, a passenger falling on a bus due to operator error or someone getting injured on an elevator or escalator because of equipment failure.
Accurately identifying the appropriate medical treatments related to injuries and illnesses in liability claims can be a complex undertaking. The nature and cause of injuries vary widely by incident; some claims include stacks (or the digital equivalent) of medical records, bills and forms that claims professionals must review as part of the adjusting process. The sheer amount of paperwork and cryptic medical terminology can make it difficult for clients and examiners to determine how preexisting conditions and other chronic comorbidities impact treatments associated with the injuries and illnesses in question.
That’s where liability nurse consultants come in. We work alongside examiners and defense counsel, providing expert guidance on claims involving particularly complicated medical histories. We review and analyze the medical aspects of a liability claim, helping to ensure a fair resolution for all parties.
Determining the nature and cause of injuries
Nurse consultants bring to the liability claims space a wide range of clinical expertise and experience on which to base their professional evaluations. They recognize subtle discrepancies, condition changes and treatment lapses or noncompliance, with an eye toward establishing a working chronology of the claimant’s illness or injuries, medical history and related course of treatment. Their training enables them to offer clinical opinions, theories of causation, recommendations for mitigating damages and meaningful investigative findings.
Engaging a nurse consultant in the liability claims process offers the examiner, responsible party and other stakeholders a comprehensive understanding of the medical aspects of the claim based on the evidence provided. (It also reduces the use of physician advisors and the amount of time defense firm paralegals spend preparing treatment timelines, leading to lower claim costs.) When examiners have a clear and thorough understanding of the medical facts of the case, they are better equipped to negotiate an appropriate and timely claim settlement.
Here is a real-world example of the value in having a nurse consultant in the claims process: When an individual visiting an establishment insured by one of our liability clients pulled open a door, the handle unexpectedly became dislodged, striking him in the knee. He alleged that his body twisted unnaturally during the incident and that the resulting injuries required knee and lumbar spine surgery. His initial claim for damages was $2.5 million.
In light of the high-dollar value of the claim and its complex medical documentation, the assigned liability team enlisted support from one of our talented nurse consultants. She reviewed the claimant’s full medical history and, based on accepted guidelines and medically approved modalities, separated the treatments that were causally related to the door handle incident from those that were unrelated and exceeded what is reasonable and customary for such an injury. Her professional opinion helped to significantly mitigate the client’s damages and ensured that the settlement was appropriate for the injury incurred at the client’s facility.
When to engage a liability nurse consultant
Liability claims professionals can benefit from turning to nurse consultants for guidance when the medical details of a case are outside their scope of experience or expertise. Aspects of the injury or treatment that may trigger the engagement of a nurse consultant include:
- A questionable causal link between the injury/incident and the treatment plan.
- A claimant with a complex history of injuries, preexisting medical conditions or chronic medical comorbidities.
- Treatments that seem to be excessive for the injury incurred, involve complex surgeries or are outside the Official Disability Guidelines (ODG).
- The medical special total (for medical expenses related to the incident) is higher than expected.
- Excessive lost work time — with or without an imposed whole person disability rating (overall level of bodily impairment) asserted.
While the majority of claims Sedgwick receives are appropriate and accompanied by legitimate documentation, there are times when the medical evidence doesn’t appear to support the claim. It’s in those cases where the knowledge and investigative skills of a nurse consultant offer the greatest value.
Program analytics clearly demonstrate that the involvement of a nurse consultant results in significantly lower liability costs and drives fair claim resolutions. The benefits of engaging a nurse consultant on a complex liability claim far outweigh the costs.