Video: Helpful Tool in Making Coverage Determinations

 

Video security cameras can be a key tool in helping identify causes of workplace injuries and assisting adjusters with investigations. Video can assist when trying to fill in the blanks of what occurred, can help approved providers determine the best treatment plan for that individual, and can also help if an appeal is filed.

Texas Option plans have outlined types of non-covered injury circumstances. One exclusion is an injury occurring under circumstances where the participant’s employment did not place him or her at a greater risk of injury than the participant would have been exposed to as a member of the general public. In these cases and others, video can be a key tool when trying to find coverage for an injured worker.

Consider these two cases that demonstrate the value of video:

 

The Case of the Twisted Knee

PartnerSource recently reviewed a case where an injured worker reported they were at their workstation when their knee locked and they fell to the ground. The injured worker reported that they possibly could have twisted their knee, ultimately causing their reported fall.

After reviewing the video with the claims team and dissecting it, it was confirmed that there was no slip, trip or fall. Video also confirmed there was no slip hazard or external occupational factor involved in this event. Based on the video evidence, the cause of the incident was determined to be from the claimant’s own body mechanics (the way they move their body) rather than an external occupational factor. As it relates to this event, the claimant’s employment did not place them at a greater risk of injury and could have occurred outside of the workplace.

 

In addition, the Texas Option Plan’s definition for an accident is defined as an event involving factors external to the participant that were unplanned, unexpected and occurred at a specific time and place. Video was able to help identify that there were not any external factors (debris or other occupational hazards) that were the direct cause of the event.

Based on the information provided by the claimant as well as the video evidence, the claim was denied for medical and wage benefits.

 

The Case of the Mysterious Fall

In this case, an associate was on the clock and walking into a workshop when they fell to the ground, injuring their knee.

When the recorded statement was obtained from the claimant, the injured employee could not provide an explanation for why they fell. The associate noted that their knee was hurting so much at the time of the fall that they did not think to look around to see if anything was on the ground that caused them to fall. In addition, they were in the workshop alone, so there were no witnesses to the incident.

Since the associate could not identify a reason for their fall, the claim was set to be denied for no greater risk for injury than the general public, and no accident, since there was no apparent external factor that caused the fall.

However, after review of the video, it was confirmed that a plastic bag was on the floor at the time of the incident, and it was determined to be the cause of the fall. By the time the area was reviewed by the safety department after the incident, the plastic bag was already gone and the area had the appearance of having no defects. But since video of the incident was preserved early by the adjuster, coverage was found under the plan. The associate received medical treatment and recovered from their injury.

 

Tips for Preserving Video Evidence

PartnerSource shares these tips for ensuring video evidence of a claim is preserved:

• Request and preserve video early in the claim process. Most employers’ video retention is not very long, and you don’t want it to get erased.
• Retain video even if an accident is not shown. Even if the video does not show an accident, yet the claimant is seen in the video, it remains important to preserve the video showing there is not an accident.
• Make sure the video is time- and date-stamped. This can become important in the claim process.
• Capture before and after. Preserving video that not only captures the event but also before and after the event is also helpful for the adjuster’s investigation. We recommend at least an hour before and at least an hour after the reported event as a good starting point when requesting length of video. (Narrowing down specifics of location and time when completing the claimant’s recorded statement can help confirm if you have the correct video time and date.) 

 

Let’s Review the Tape

No two claims will be exactly the same, and video can serve in a variety of ways to help with a complete and thorough claims investigation. PartnerSource assists clients on reviewing coverage determinations and resolution strategies. When you have questions on coverage, you can partner with your PartnerSource team to assist in identifying benefits.