The nurse reviewer in this case spotted several inconsistencies in this tractor-trailer related personal injury. Upon analysis, these raised red flags about the soundness of the claim.
The matter involved a 55-year-old male who was the restrained driver of a tractor trailer that was stopped in traffic when it was rear-ended by another tractor trailer. The driver sought emergency department care for cervical spine, bilateral shoulder and right wrist/hand pain five days post Date of Loss and again six days after that. The claimant then treated with a chiropractor for cervical spine, shoulders, and upper back pain, with treatment ending in early March 2020.
Mechanism of Injury (MOI)
In this key component of the claim analysis, the reviewer found that the claimant’s initial complaints – as found in the police accident report and the physician records – aligned with the MOI, specifically a right wrist/hand injury. However, the nurse reviewer found that, while the subjective complaints possibly aligned with the MOI, the complaints later expanded. These expanded complaints raise doubts about whether the areas of impact on the vehicle and on the claimant’s body actually correspond to the subjective complaints at the heart of the claim.
Comparison of pre and post Date of Loss (DOL)
The reviewer reported that no prior medicals were submitted, making a pre and post DOL comparison impossible. However, post DOL x-ray records were in the claimant’s records, and these were consistent with pre-existing, mild degenerative changes.
The record revealed several data points that raised red flags to the nurse reviewer:
- Although the MOI initially aligned with subjective complaints and objective exam findings, the MOI was not congruent with the claimant’s expanded complaints involving additional body parts.
- The claimant delayed seeking initial treatment, and the subjective complaints were reported too late in the timeline to correlate with the MOI.
- The clinical exam on the DOL did not definitively define the acuteness and/or chronicity of subjective complaints.
- The radiological findings in the claim did not support acute or chronic pathology, Specifically, the initial x-ray supports pre-existing joint degeneration of the right wrist, and no other x-rays were done. The differences between acute verses chronic radiological findings is critical to the defense.
Mild degenerative changes, therefore. could have been temporarily aggravated by anything, not just the MOI. Additionally, the reported MOI must hold true when trying to determine causation issues. Based on the clinical and radiological exams and findings the MVA did not advance any pre-existing pathology, though a temporary, self-limiting aggravation was possible.
The nurse reviewer identified two key data points important to the claim and mitigation of the overall exposure: 1) pre-existing condition and 2) overtreatment by the claimant’s chiropractor. The big teachable moment in this case is that delays in seeking treatment and late addition of injured body parts are tangible defense points.