Nurse consultants bring great value to liability claims

Nurse consultants bring great value to liability claims

Many in our industry are familiar with the case management role of nurses in the field of workers’ compensation, where they support injured and ill employees and oversee the treatment and recovery process. But did you know that nurses can also play a vital role in settling liability claims that involve illness or bodily injury? Known as liability nurse counsellors, they use their medical knowledge to help clients and claims professionals decipher medical records and conditions, evaluate treatment plans, mitigate damages and facilitate resolutions. timely and appropriate.

Support Fair Settlements

Our nurse consultants are uniquely qualified to assess medical facts associated with general liability, personal injury and automobile claims. The types of claims we review may include a retail customer who suffered a fall in store, a consumer suffering from food poisoning from a contaminated product, a passenger falling on a bus due to an error in the operator or a person being injured in an elevator or an escalator because of the 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 depending on the incident; some claims include stacks (or the digital equivalent) of medical records, invoices, and forms for claims professionals to review as part of the adjustment process. The amount of paperwork and cryptic medical terminology can make it difficult for clients and examiners to determine the impact of pre-existing conditions and other chronic comorbidities on treatments associated with the injuries and illnesses in question.

This is where liability nurse consultants come in. We work alongside examiners and defense attorneys, providing expert advice on claims involving particularly complex medical histories. We review and analyze the medical aspects of a liability claim, helping to ensure a fair resolution for all parties.

Determine the nature and cause of injuries

Nurse consultants bring to the liability claims space a wide range of clinical expertise and experience upon which to base their professional assessments. They recognize subtle discrepancies, changes in condition, and failures or non-compliances with treatment, with a view to establishing a working chronology of the claimant’s illness or injury, medical history and related treatment. Their training enables them to offer clinical opinions, theories of causation, recommendations for mitigating harm, and meaningful investigative findings.

Engaging a nurse consultant in the liability claim process provides the reviewer, responsible party, and other stakeholders with a comprehensive understanding of the medical aspects of the claim based on the evidence provided. (It also reduces the reliance on medical consultants and the time that defense firm paralegals spend preparing for processing times, which reduces claim costs.) When examiners have a clear and thorough understanding of the facts of the case, they are better equipped to negotiate an appropriate and timely claim settlement.

Here is a concrete example of the value of having a nurse consultant in the claims process: when an individual visiting a facility insured by one of our civil liability clients opened a door, the handle came off unexpectedly, hitting him in the knee. He alleged that his body twisted abnormally during the incident and that the resulting injuries required surgery on his knee and lumbar spine. His original claim for damages was $2.5 million.

In light of the high value of the claim and its complex medical documentation, the assigned liability team brought in one of our talented nurse advisors. She reviewed the plaintiff’s complete medical history and, based on accepted guidelines and medically approved modalities, separated treatments that were causally related to the doorknob incident from those that were unrelated and exceeded what is reasonable and customary for such an injury. His professional opinion helped to significantly mitigate the client’s damages and ensured that the settlement was appropriate for the injury sustained at the client’s facility.

When to Hire a Nurse Accountability Consultant

Liability claims professionals may benefit from turning to nurse consultants for advice when the medical details of a case are beyond 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.
  • An applicant with a complex injury history, pre-existing medical conditions or chronic medical co-morbidities.
  • Treatments that seem excessive for the injury suffered, involve complex surgical procedures or do not comply with official disability guidelines (ODG).
  • The special medical total (for medical expenses related to the incident) is higher than expected.
  • Excessive time loss from work – with or without an asserted whole person disability rating (overall level of physical impairment).

Although the majority of claims received by Sedgwick are appropriate and accompanied by legitimate documentation, there are times when the medical evidence does not appear to support the claim. It is in these 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 leads to a significant reduction in liability costs and leads to fair claims resolutions. The benefits of engaging a nurse consultant in a complex liability claim far outweigh the costs.

By Diana Shik

Courtesy of sedgwick


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Disclaimer: publishes independently generated writing from a variety of workers’ compensation industry stakeholders. The opinions expressed are solely those of the author and do not necessarily reflect those of