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Insurance Claims “Believe It Or Nots”

© Andrey Salamchev

Managing insurance claims is not a fun job. But every once in a while, a claim comes along that no doubt raises an eyebrow or two. Here, are some actual insurance claims that border on the bizarre.

Claim #1: You thought slip and falls were dangerous; beware of “Sleep and Fall” accidents as well!

Facts: An elderly gentleman was sitting in a chair in a physician’s waiting room reading the paper when he fell asleep. After falling asleep, he fell forward out of the chair striking his head and causing laceration type injuries.

Claim: An attorney demand letter was sent claiming facts that were inconsistent with those noted above. The attorney demanded $100,000. After restating the original facts of the case on several occasions, and with new theories rebutted by the claimant’s attorney, the insurance carrier maintained its position of minimal liability.

Risk Lesson: Ensure that waiting patients or customers are seated in sturdy chairs; located away from swinging doors; and far from shelving units or other blunt instruments. If a person appears drowsy, make sure to monitor them closely!

Claim #2: What happens when one of your employees accepts a package on behalf of a neighboring business, but then destroys that package and its contents?

Facts: While performing construction in a strip center shopping plaza, a FedEx delivery driver presented a package in error to a construction supervisor on the project. The package was being sent to a former business that had recently moved from this address. For unknown reasons, the supervisor elected to open the package, review the contents, and proceed to take matters into his own hands.

Claim: A claim was made to the construction company by the shipper of the package for the full value of its contents – a rare gun valued at $10,000. The package shipper was a licensed firearms dealer transferring ownership to another licensed dealer at this address. It is a criminal offense for anyone else to possess this type of firearm other than a licensed dealer. The construction supervisor who signed for the package believed that the firearm had been sent in conjunction with some sort of terrorist activity, so he took it upon himself to cut the gun into four pieces with a saw owned by the construction company. He then proceeded to discard all four pieces into separate dumpsters around the city. Upon investigation, authorities were able to track down the whereabouts of the missing package contents. Two pieces of the firearm were recovered from dumpsters, thereby corroborating this story!

Risk Lesson: Do not accept a package addressed to someone else, and do not destroy package contents that you have accepted on behalf of someone else, even if you believe you are doing a societal good deed (as this man believed)!

Claim #3: Workers’ Compensation claims come in all shapes and sizes. Employers work hard to prevent claims and limit their potential losses. This includes terminating an employee before a claim even has a chance to arise. So how could a claim occur once an employee is terminated?

Facts: A difficult employee at a company was terminated over a lunch meeting on a Monday. Or so the owner thought. The next day, this “former” employee visited a private job site, gaining access from a known security guard. Three hours later, the employee arrived back at the guard gate in a state of disarray, including a scrape to his head and soiled clothing. He claimed that he was there to retrieve a personal article and tripped and fell, hitting his head and rendering himself unconscious. When he awoke, he made his way to the guard gate to call for medical assistance. Notably, two weeks prior to the alleged incident, this employee inquired as to whether or not he would be considered an employee and be covered under workers’ compensation.

Claim: When the “former” employee presented his claim to the employer, he stated his facts and claimed he was never terminated the day prior. He merely acknowledged a discussion had occurred. The “former” employee sought ongoing treatment and lost wages due to his injury “on the job.” The employer informed the employee that there was no coverage in place as he had been terminated.

Risk Lesson: When you intend on terminating an employee, make certain to do so with written notice or with witnesses to a verbal termination. Otherwise, you may encounter employees filing workers’ compensation claims long after they have been let go.

Claim #4: Don’t underestimate the tenacity of someone filing a claim on their own behalf!

Facts: Three vehicles were traveling west on a roadway. The first of the three vehicles stopped to make a left turn into a parking lot. At the same time, the driver of the third vehicle was dialing his cell phone and failed to stop, thereby hitting the rear end of the second vehicle, propelling that car into the rear end of first car. Damages to the second car were estimated at $2,000. The responding law enforcement officer reported that there were no injuries. In addition, the driver of the second vehicle did not have a valid driver’s license and was issued a citation for that offense. The driver of the third vehicle was cited for careless driving, having caused the collision.

Claim: The driver of the first vehicle (Driver 1), who was not at fault, filed a handwritten civil lawsuit and served it upon not one, but three officers of the company that employed Driver 2. In his narrative, Driver 1 cited his outrage that a company would allow an employee with a suspended license to drive a company vehicle. At the time of the accident, the employee (Driver 2) was said to be in the process of reinstating his driver’s license. Driver 1 never claimed any bodily injury or other damages, other than his outrage noted above. In the last line of his lawsuit was a demand for $75 million!

Risk Lesson: It is critically important to verify your employees’ driving records and licenses, while making sure to add any employees who may drive on your company’s behalf to your commercial insurance policy.

Claim #5: Water damage claims by themselves can be challenging and expensive. But, when you combine this with a bad adjuster and a difficult claimant, the result is a worst-case scenario.

Facts: A home was damaged from a water leak that occurred over an extended period of time. Mold was detected in the home and it was abandoned a short time later. This resulted in the accumulation of extended living expenses for a substitute residence.

Claim: A resident of the home claimed that he needed surgery to “remove mold from his head, which he incurred from the home.” In addition, the long duration of trying to repair the home and erase the problems that arose from the initial-adjuster-gone-bad caused the claim cost to escalate beyond reasonable. The delays in getting the work contracted by legitimate contractors; as well as, the interference that took place from an attorney and public adjuster representing the homeowner all contributed to the cost of the claim.

Risk Lesson: Even when it appears that the adjuster is properly managing the claim, oversight, intervention, and verification protocols must be in place.