Claims Management: The Case of the Out-Hustled Pool Hustler

Chalk Up $100K Savings to Vigilant Persistence

Most employees who get hurt on the job just want proper medical treatment, fair compensation, and the chance to get back to putting in an honest day’s work. That’s what Vigilant is here for, to assist employers and employees with streamlining the entire return-to-work process. But every now and then a simple case involving a minor accident can spiral into some major scratch.

A Vigilant Retro member was saved from nearly $100,000 in time loss and mitigating claim costs after Vigilant 8-balled a case involving an employee who wouldn’t let an on-the-job fender bender get in the way of his dreams of becoming a professional pool player.

Opening Break
Taking some “cues” from conversations with the employee, who had been injured and put on disability after a company vehicle he was driving was rear-ended, the Vigilant claims manager decided to conduct an investigative follow through. The extensive restrictions from the employee’s attending provider, a chiropractor he had seen previously, didn’t gel with the minor $600 damage to the vehicle. After a little digging and discovery of previous claims and payments for pain and suffering, it was beginning to look like his employer might be getting snookered.

In the Pocket
Long story short: after talking to fellow employees and discovering that not only had the claimant been bragging of an upcoming big payday from the third-party insurance company, but also of participating in out-of-state pool tournaments, a fraud investigation was opened by the Washington Department of Labor and Industries (L&I). For someone suffering from “severe neck, back and shoulder injuries” with restrictions on bending, stooping, and raising his arms, the employee didn’t appear to be in any pain in videos obtained of him raising a trophy after a second-place showing in a pool tournament.

Game Ball
The employee and his chiropractor were together confronted with the video evidence. The shocked employee was immediately released for return to work without restrictions, and time loss was halted. Even though the employer arranged light duty work answering phones, the employee continued to complain of pain and continuously called in sick or left work early. By now it was apparent the employee just didn’t want to be there and wasn’t an asset to his employer. The increasingly frustrated employer feared they might just be stuck behind the 8 ball on this one, but then the claims manager brought in their dedicated Vigilant employment attorney (at no additional cost) to line up a strategy. With the help of their Vigilant team, the employee was separated from the company.

No Rubber Stamps
At Vigilant, we never rubber stamp a workers’ comp claim. Our goal is to move the claim as quickly as possible to closure, but not so fast that we can’t spot a red flag (and we’re really good at spotting them). If you suspect anything amiss with a claim, retro participants can call their Vigilant team and we’ll do our best to see that you don’t rack up any more time loss or expense than necessary.

Learn more about our Washington Retro Program today and how we work to reduce your overall workers' comp costs.