Why there is always more to the story when assessing fall-related claims, cases

Editor’s note: This is the first in the three-part series on evaluating fall-related claims and cases.

A misstep. A wobble. And, then, bam. In a millisecond, a trip, slip or fall can lead to life-changing injuries, along with bulging medical files, an insurance claim and, often, a court case.

Indeed, the business behind fall-related insurance claims and court cases is big. At home, at businesses and at work, falls cause thousands of injuries and hundreds of deaths each year, leading to billions of dollars in workers’ compensation costs and medical claims.

Here at MKC Medical Management, attorneys and insurance adjustors regularly hire us to review and advise on cases that involve a fall. In fact, our practice has reviewed hundreds of claims involving various kinds of falls during the past 20-plus years.

We aren’t biomechanical engineers. But, as legal nurse consultants and clinicians, we have a fundamental understanding of fall mechanics. Claim strategies are often based on understanding the mechanism of injury and the resulting bodily injury. Without that expertise, you risk missing out on critical details of a case and have less control over its final outcome.

Always more to the story

Environmental hazards – icy sidewalks, uneven curbs, bumpy pathways – typically drive personal injury and property casualty claims. But, for insurance adjusters and attorneys, when it comes to determining what caused a fall injury, there’s always more to the story than the weather report and emergency department records.

The challenge when evaluating most falls is determining the validity of the allegation: Was it really the rain-soaked tiles that caused the fall or could there be another reason – the claimant’s high heels or a chronic illness that makes the person unsteady on their feet.

Not all falls are the same. In fact, each type of fall – from a trip to a slip to a crumple – has its own distinct thumbprint.

To completely evaluate a fall claim, a thorough understanding of the biomechanics of the fall, a complete story about what happened and a full assessment of what’s inside those complex medical files is vital.

Who’s at risk?

Slips, trips and falls make up 15 percent of all accidental deaths, according to the federal Occupational Safety and Health Administration. They also are a leading cause of fatalities – second only to motor vehicles.

On the job, injuries from falls produce a major strain for employers. In 2014, more than 260,000 private industry and state and local government workers missed one or more days of work because of a fall, according to the Bureau of Labor Statistics. That year, almost 800 workers died.

Those lost days and expenses add up. The National Safety Council estimates that the annual costs to cover workers’ compensation and medical costs from occupational fall incidents total $70 billion.

Perhaps, not surprisingly, construction workers, often working from precarious perches atop tall buildings, account for the highest frequency of deaths from falls, according to the Centers for Disease Control and Prevention. Employees in health services and the wholesale and retail industries have the highest risk for injuries from falls that don’t cause death.

Senior citizens also are in danger when they tumble. Each year, nearly 3 million people age 65 and older are treated in emergency departments for fall injuries. One out of five of those falls cause a broken bone or head injury, the CDC says.

What’s more, the unintentional fall death rate has been on the rise for older citizens – 43 deaths per 100,000 in 2005 and nearly 60 deaths per 100,000 in 2014, according to the CDC. Medical costs to treat seniors, who suffered a fall, total $31 billion each year – about two-thirds of those costs come courtesy of hospital bills.

Why we fall

It’s easy to understand why construction workers or retail workers, who are working in unsafe environments or are constantly on their feet, are more likely to fall than other workers. Seniors also are at risk because they may have lower body weakness; vision problems; foot pain; or use medicines that could make them less sure-footed.

But science – and experience – shows us that just about anybody can be prone to a fall for all kinds of reasons – wet flooring, uneven sidewalks or improper footwear.

Coming next week: We’ll cover the reasons why we fall and how both the central nervous system and physical movements play a role.