While the records in this case lined up with the complaints, the claim was deemed excessive because of the claimant’s age and her pre-existing history.
First, here’s what happened. The claimant – an 81-year-old female – was injured when a truck struck her car (she was standing next to it), pushing it into her and causing her to fall and sustain…
- An open fracture of her left ankle and
- A degloving injury to her right heel
She underwent an ORIF with irrigation and debridement of both wounds, required extensive wound care and ultimately spent two months in a subacute rehabilitation facility. After discharge, she required the services of in-home nursing visits and physical therapy visits. Extended recovery and rehab within the elder population is common and often involves great ancillary services and time as this population is at high risk for complications, impacting pre-existing conditions and difficulty in returning to pre-injury baselines.
It was alleged that because of these injuries she will never fully recover and return to her pre-DOL status where she was living independently and managing her Activities of Daily Living. A demand for $1 million was made. It is fairly common to see independent functioning elder persons sustain an injury and develop multiple complications resulting in a suboptimal recovery. Much of this has to do with baseline physicality regarding musculoskeletal, respiratory and cardiac systems. While elder persons can function very well when everything is going well, they often do not have the physical reserves to overcome a significant event or injury.
Understanding these fundamentals when working through a claim involving an elder person is critical to the analysis and reserve management.
Mechanism of Injury (MOI)
The claimant’s injuries were generally consistent with the MOI, although there was some conflicting information regarding whether or not her car ran over her legs or if she was only struck by the car and fell. According to the nurse reviewer’s analysis and considering the severity of her injuries, it is likely that her car was dragged over her, resulting in the left ankle fracture and the degloving injury on her left foot.
Comparison of pre and post Date of Loss (DOL)
The claimant had previously fractured the left ankle in the 1980’s. So, she was already at risk for the development of traumatic arthritis in the joint. The medical records in the case indicated that she was completely independent prior to the DOL.
Nevertheless, pre-DOL records were minimal. Additional records would be helpful to validate her claim if this is the case.
The bottom line is that even though the insurer appears liable in this claim, the injury was devastating. When evaluating the claim value all pre and post DOL medical conditions, including age will be considered. The claimant’s ability to fully return to her pre-DOL baseline is unlikely.
Moreover, the claimant’s records revealed the pre-existing conditions of a blood/bone marrow cancer, leukopenia, anemia, and lupus. A 9 mm cyst on the right ovary seen on full body CT was suspicious for a malignancy. It’s important to note that ovarian cancer survival rates beyond 1-5 years are low if the cancer is in advanced stages.
Several take-aways jump out from this case…
- Take a heightened look at cases involving elderly persons. Expense, time and recovery are often increased and extended because they are at risk for complicated and suboptimal outcomes.
- A sound record review has the potential to mitigate the overall exposure.
- An 81-year old female with pre-existing cancer diagnoses would not be expected to exceed her life expectancy for many more years.