Success Stories

Massachusetts: Persistence yields $200,000 in found money (major insurer)

IRG recently obtained a $200,000 recovery for an insurer on a Massachusetts second injury fund claim that had not been pursued by either the claims adjuster or defense counsel.

The claim involved an employee who suffered a fatal heart attack during the course of his employment and over $500,000 was paid to the widow by the insurer.

The insurer was eligible to recover $220,000 from the state second injury fund if it could be established that the employee's death had been caused in part by a pre-existing condition and that this pre-existing condition was known to the employer prior to the death. At the time of settlement of the claim, neither the claims adjuster nor defense counsel had identified or pursued the recovery opportunity.

As part of a regular, free, on-site file review, IRG identified the recovery opportunity. Success was contingent on proving that prior to the employee's death, at least one person with managerial authority had been aware of a prior heart condition. Among the obstacles to proving this were the facts that the company owner was deceased and the widow was less than cooperative. Undeterred, IRG contacted one of the employee's former co-workers who supplied the name of the employee's foreman. After tracking and finding this foreman through the local Electrical Workers Union, IRG learned that he was unaware of the employee's previous heart condition. However, this foreman was able to provide the name of a superintendent who provided a sworn affidavit indicating that he had been aware of the employee's heart condition prior to his death.

After obtaining the required expert medical opinion, and organizing a detailed proof of the claim, IRG was able to negotiate a recovery of $200,000, an outstanding resolution that was essentially "found money" for this insurer.

Massachusetts: Forensic review work - IRG recovers what others missed (major auto manufacturer)

Our litigation group tried, and won, a seminal case establishing that there is currently no statute of limitations to file a claim for reimbursement with the Massachusetts Second Injury Fund on claims with dates of injury between 12/10/85 and 12/23/91.

Knowing that a major auto manufacturer had a plant in Massachusetts during that time period, we researched how much SIF reimbursement they had recovered on workers' compensation claims with dates of injury during this time frame. The answer, not surprisingly, was "none".

We offered to do a free on site file review of selected Massachusetts claims, and found 25 potential claims out of 100 files. Within 11 months of receiving the files, we obtained recoveries worth over $550,000, with another $375,000 potential in future recoveries.

Forensic review work - IRG recovers what others missed (major newspaper)

We researched how much SIF reimbursement they had recovered on workers' compensation claims with dates of injury during this time frame. The answer, not surprisingly, was "none." We further learned that the newspaper's claims were administered by one TPA through 1995 and by another from 1995 to date. Since we had a good relationship with both TPAs, we were able to easily coordinate reviews of these closed files.

We conducted a free review of 35 of the newspaper's claims, and in a follow-up review, an additional 18 claims were identified. We have recovered over $660,000, with another $70,000 potential in future recoveries.

Massachusetts: Pushing the envelope increases recoveries (major non-profit organization)

Our litigation group successfully expanded the legal definition of "knowledge" of a pre-existing injury or disease in order to achieve reimbursement. We also utilized the knowledge and skills of a doctor trained in second injury fund issues to prove that awareness of high blood pressure is awareness of pre-existing heart disease. Our results were extraordinary, resulting in a recovery of $1,200,000.

Massachusetts: Fighting for our clients' rights

Our litigation group utilized a test case to establish that the Massachusetts Trust Fund is not entitled to the defense of sovereign immunity and that interest is, in fact, owed on claims for reimbursement that reach a hearing decision. This gives extra incentive to the Trust Fund to expedite resolution of these claims for a quick settlement. Winning this case has provided our clients with at least an additional $600,000 in recovery.

New York: Faulty legal analysis by insurer and their counsel leaves case worth $500,000 untouched

An insurance company adjuster investigated and, upon advice of counsel, ruled out Section 15-8 (second injury fund) reimbursement. The reason cited was that the employee was no longer treating for hypertension, the alleged pre-existing condition upon which a second injury claim could be based. Both adjuster and counsel concluded that the evidence did not support that the injured employee had a permanent condition.

Upon review, we found that medical records did confirm that the employee's hypertension normalized after his work-related stroke, and his doctors had discontinued his blood pressure medication. In most cases, the inability to demonstrate that the employee continues to treat for the alleged pre-existing, permanent, condition is devastating to the second injury claim.

However, we applied an alternative legal theory by arguing that, based on the nature of the disability that ensued, the employee's pre-existing hypertension played a clear and contributory role in the employee's work-related stroke. With this argument, we succeeded in obtaining a full concession for reimbursement at a pre-trial conference with Special Funds. Prior counsel missed the point that the critical issue was not treatment, but rather, that "but for" the prior condition, the injury would not have occurred.

New York: Less than zealous investigation leaving $244,000 un-recovered

Prior to our involvement, this case was presented to Special Funds at a pre-trial conference, but was adjourned because the adjuster failed to produce sufficient medical evidence documenting a prior, permanent impairment. The adjuster investigated and concluded that they could not locate the employee's prior medical records related to the employee's heart surgery and back surgery. As a result, pursuit of Section 15-8 (Second Injury Fund) reimbursement was abandoned by the adjuster.

IRG uncovered the file at a file review well after the claim was abandoned. We were ultimately able to locate and obtain records concerning both the employee's triple by-pass surgery (even though the adjuster's investigation uncovered no such evidence) and x-rays documenting the employee's prior lumbar surgery. IRG presented this evidence to Special Funds at a pre-trial conference and obtained a full Section 15-8 concession that eventually resulted in a recovery of over $244,000.

New York: Overcoming Special Funds (second injury fund) defenses

Prior to our involvement, a second injury fund representative moved at hearing to have the Special Funds relieved of liability based on the facts of another case, which, in our opinion, did not apply in this situation. The Special Funds representative argued that, based on the "Harisiades" case (which requires that the prior impairment be separable from the work-related occupational disease) the Fund should not be liable, and requested that the workers' compensation judge enter a finding that Section 15-8 does not apply.

IRG uncovered this case at a forensic file review and subsequently aggressively rebutted the Special Funds defense. In examining the Harisiades case, we were able to clearly distinguish the facts of our claim from those of the Harisiades case and prove to the Special Funds that the principles of Harisiades did not apply. We obtained a full Section 15-8 concession in this matter at pre-trial conference with this rebuttal argument, resulting in $374,000 of recovery to the client.

New York: Less than aggressive advocacy in interpreting medical records

Reports in the adjuster's file indicated that Section 15-8 did not apply in this case, based on prior findings of no heart disease. During our initial review of this file, we did indeed find that prior medical records did not show a definitive diagnosis of heart disease. We noticed, however, that the employee took several different medications, which are generally associated with treating hypertension and chest pains related to heart disease. The claims examiner for this client either wasn't aggressive enough or simply did not understand how to use the medical evidence effectively.

We felt that the evidence could have been stronger, but took an aggressive stance on behalf of our client with the Fund, resulting in almost $80,000 of recovery dollars to our client, and future estimated recoveries of $61,880.

New York: adjuster's inadvertent in-house errors compromising second injury fund recovery

In this case, while we were pursuing a viable recovery opportunity, we noticed that the client's adjuster was attempting to withdraw its Section 15-8 (Second Injury Fund) claim at the Board in order to settle the case.

We immediately alerted the client to the situation and advised that withdrawing their claim and/or entering a settlement without Special Funds' consent would preclude reimbursement. This potential, inadvertent, adjuster error would have left the client responsible for the entire settlement. With our guidance, the result was a recovery of an estimated $60,725, and an estimated future recovery of $54,300.

New York: Maximizing total revenue for a large insurer

Total outsourcing can maximize recoveries. A large insurance company had an active second injury fund recovery protocol; however, it was controlled and managed on a case-by-case basis by individual claims adjusters. When we took over the recovery program, the client had a backlog of several years in reimbursement requests on file and was receiving only about $600,000 a year in reimbursement from the NY Special Funds.

Within two months of contract inception, we requested an additional $730,000 in reimbursement and increased this amount to $6,327,014 by the following year. To date, we have requested over $80 million for this client with annual recoveries averaging over $13 million. The estimated future recovery of these claims is over $216 million.

New Hampshire: Staying focused means the job gets done

When there is no focus on SIF recovery, slippage occurs and the traditional method of claims handlers referring cases to counsel to perfect a claim is not effective. In a recent insurance company review, we noted that a large defense firm was communicating with the adjuster about a potential second injury fund claim in New Hampshire, but each of the parties was depending on the other to get the job done. In our file review report, we reported this situation, but the carrier chose to continue on the same path.

Several months later, a few short weeks before the deadline to perfect the claim was about to lapse, the carrier recognized that the ball had been dropped and called on us to help put the claim together since the adjuster/lawyer method was not working. We were able to perfect and submit the claim for reimbursement just before the filing deadline, resulting in an accepted claim worth over $100,000 in reimbursement to the carrier.

New Hampshire: Using focused experts with the experience to find proper evidence

In a recent file review for a new client, we identified a potential SIF claim because of a medical record that suggested that the claimant had a prior back condition. The claims adjuster told us that it was not a potential SIF claim, and that she had already spoken with the employer during her initial claims intake interview, and determined that the employer did not have the requisite written records to support that it knew of a prior permanent condition.

After reviewing the file, we re-conducted the employer interview, explaining to the employer that they must have had certain written reports in their records if the claimant was doing this particular job for the employer. Following our lead, the employer did find some written documentation (prerequisite in New Hampshire) which showed that the employer did have written records stating the claimant had "chronic back pain" prior to the second injury. We were able to use these records to put together a full claim to the Fund.

South Carolina: Pushing back on the state fund to expand recovery opportunity

Working with local counsel, IRG obtained a decision from the South Carolina Workers' Compensation Commission against the South Carolina Second Injury Fund that should make it easier to resolve cases with the Fund. The Fund appealed the decision to the District Court level and the District Court affirmed the Commission’s decision awarding reimbursement. The Fund has decided not to appeal the issue.

The Fund initially denied the claim because the claimant's pre-existing condition did not fall within one of the listed statutory conditions, including the so called "catch all" under paragraph 34B. When filing the claim, we recognized that the prior permanent impairment did not have to be one that was listed in the statute but only had to be 1) a permanent impairment that was 2) an obstacle or hindrance to obtaining employment should the claimant become unemployed.

The Fund interpreted the listed conditions as an exclusive list rather than a presumptive list. The Full Commission affirmed the single Commissioner's decision which stated: "Nothing in §42-9-400 prevents an employer from establishing by other means that a pre-existing condition was a hindrance or obstacle to employment. In other words, an employer is not limited to establishing his claim via a presumptive condition."

Georgia: National brief helps bank to increase recoveries

Having national experience can be beneficial because work done in one jurisdiction can often be applied in another jurisdiction. This proved to be the case with a bank in Georgia that had been having claims denied by the State Fund in Georgia. Claims for employees with a preexisting impairment of "obesity" were being denied on the grounds that obesity is not a disease. We used the brief that we had argued successfully in another jurisdiction to establish a claim for reimbursement in Georgia, resulting in a $100,000 reimbursement.

Florida: Files with dates of injury prior to the cut-off date of closed jurisdictions may still have value

In a review of a client's Florida cases with older dates of injury, we found a file, where many years prior, our client began to pursue a claim against the Second Injury Fund. However, because the Fund continued to request additional information, and because of the carrier's misconception that because the Fund had closed, recovery was not possible, the carrier seemingly gave up on the claim. Once we took over the handling of the file, we immediately communicated with the Fund to determine the outstanding issues. We realized that the Fund was raising an improper legal defense to the claim. Using this argument, a claim was filed, and within months it was settled with reimbursement to the client in excess of $200,000.

District of Columbia: Experts know where to look

In a review of Washington, D.C. cases with older dates of injury, we found a claim that was being defended vigorously as the claimant was seriously injured and was looking to claim permanent and total disability. Because of our expertise, we were able to point out the reimbursement potential on the claim. This led to us obtaining an agreement from the Fund that resulted in an initial retroactive reimbursement of over $300,000. The claim is still open, the claimant is receiving permanent and total disability, and the carrier is getting reimbursed 100% of the indemnity.

District of Columbia: Closed Funds Still Have Significant Recovery Potential

In a free review of a client’s Washington, D.C. files, IRG identified an old, open file with potential Second Injury Fund relief. IRG perfected the file for recovery, and within a year IRG obtained a reimbursement for the client totaling almost $500,000. In addition, indemnity on the claim will continue to be reimbursed by the Fund for the life of the claim, estimated to be worth another $315,000. The 17-year-old file had never been identified as a potential SIF claim before IRG’s review.