A former workers' comp regulator texted me a story out of Texas this morning. It describes the case of 73-year-old Jane Hays, who in the twilight of a long insurance career suffered major injury in a car crash while driving home from a meeting called by the same insurance company that is now denying her claim. Hays suffered multiple broken bones, including a shattered pelvic ring, and her right leg was amputated below the knee.

Hays is the Director of Employee Benefits and Risk Management for the Temple Independent School District, and she sits on the board of the Texas Political Subdivisions (TPS). TPS is a non-profit insurance carrier administering workers’ compensation benefits for local government entities. They insure the Temple Independent School District.

TPS had called the meeting that Hay's was attending. It was in a location that was not on her normal commute to and from work. She was driving home from those meetings when the accident occurred. And TPS wasted no time in issuing a denial of her claim, sending the notice on the day her leg was cut off.

They maintain it is “gray area”, and the claim “had to be denied so that the Texas Division of Workers Compensation and possibly the state courts can rule on whether TPS should pay the claim”. TPS executive director Randal Beach was quoted as saying, “I have to follow the law. I have to treat it like another claim. It doesn’t matter how much I love Jane, and I do.”

I'm very happy that everyone loves Jane, although I am sure at this point the feeling is rightfully not mutual. The issue is not special treatment for a member of the TPS Board of Directors. The issue is that this sounds like a claim that should be paid. Period. She was traveling for the benefit of her employer, in this case the company for which she serves as a director. This was not a normal commute under the Going and Coming rule that many states follow. It appears to be special travel for the benefit of the employing entity.

They call it a gray area. I call that bullshit. But even more concerning is the comment that they need to treat this “like another claim”. Is this a glimpse of standard claims practice at the company; deny and delay, until the courts make us do otherwise? The concept makes me shudder. And we wonder where ProPublica gets stories like it does.

Here's a radical concept. Business travel is generally not exempt in comp. Pay the Goddamn claim.

I am not alone in my feeling on this case. The former regulator who sent me the article was outraged, and told me that this claim should be absolutely covered. No gray area for him. Sam McMurry, Executive Director at the Texas Self Insurance Association, posted an excellent article on LinkedIn yesterday condemning the action. The source article is appearing in LinkedIn posts elsewhere as well.

Others seem to see this as fairly black and white. It sounds like the carrier is the only one seeing gray here. And that has everyone seeing red.

So, we again find ourselves staring into the abyss of another self-inflicted wound over the handling of a claim. The fact that this injured worker is “one of our own” is irrelevant. The fact that should be concerning us on a broader scale is the potential practice of denying the obvious. This only costs us greatly in the long run, and is a blatant violation of the Grand Bargain on which the system is based.

And what of the cost of denial? Beyond litigation costs, beyond extended medical costs, beyond lengthened indemnity periods; what is the cost to the company and industry in reputation? A relatively obscure outfit now finds itself on the verge of a national story over its handling of an injured worker. An industry once again must face its greatest flaws. Trust erodes, and confidence fades further away.

I expect the courts will reinstate Ms. Hays rights in this matter, even though the delay itself will likely be damaging. For the rest of us, however, there will be no treatment forthcoming to bandage our wounds. Our reputation as an uncaring and heartless industry will be further cemented in the minds of many, aided by the potentially irresponsible actions of a few.

Is it worth the cost???

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