Claims professionals are uniquely situated to witness the delivery of the promises outlined in the insurance policy contract. In fact, they are often the catalyst for delivery of the promises made. This places significant responsibility on every claims professional to "get it right." Pay too much, and the insurer loses profits; pay too little, and the insurer faces lawsuits, additional expenses, and even loss of reputation. "Getting it right" is not always easy and is particularly difficult when evaluating bodily injury claims.
In addition to a basic understanding of medical terminology, knowledge of treatment options, length of disability, the likelihood of permanent impairment, and the necessity for ongoing care is required to properly evaluate a claim for damages based on an injury. In this article, we will be discussing the types of wounds that claims professionals may encounter and what should be considered when evaluating these types of injuries.
Types of Wounds
For the most part, accidental injuries tend to be traumatic in nature. Traumatic injuries are a result of external and accidental force. Traumatic injuries are distinctly different from congenital disorders or disease processes. A congenital disorder exists at or before birth, while infectious diseases occur due to exposure to viruses or bacteria or are caused by an allergic reaction to a chemical.
A traumatic injury may weaken an individual, making that person susceptible to an infectious disease. The existence of a congenital disorder or even a comorbidity, such as diabetes or obesity, can complicate the healing process, resulting in extended disability. Evaluation of these claims becomes even more challenging for the claim professional.
The force of accidental trauma can result in a visible wound. While we generally think of wounds as being a break in the skin, not all wounds actually result in skin breakage. There are several types of wounds:
Bruises, also called contusions, are caused by forceful trauma and, while they usually don't involve a break in the skin, the mere force of the trauma can cause the skin to break. Crushing injuries almost always result in bruising, often with no skin breakage. The discoloration from bruising is called ecchymosis, the typical black and blue marks left by breakage of blood vessels under the skin into an area with no release through bleeding. While bruising may appear dreadful in photos, it usually subsides with time.
A severe contusion may result in the formation of a hematoma, which occurs when blood is trapped under the skin and forms a pool, forcing the skin to push outward. While ecchymosis occurs when the blood is disbursed under the skin, a hematoma occurs when the blood is trapped in a specific area and the pressure of the blood loss balloons the skin. The more severe the contusion, the longer the recovery period, as the blood is reabsorbed into the body. Hematomas can result in damage to the surrounding epidermis. Deep hematomas can even damage vital organs, such as the kidney or liver.
Cuts are a common injury due to trauma and can be described in several ways. An incision is a cut to the skin that is sharp and smooth at the edges. An incision is very well defined. It can be of any depth, with the deepest incisions the most harmful as they are more likely to harm other tissues or organs. However, a shallow incision in a vulnerable location can be considered very severe, particularly if blood vessels are damaged or if the incision is very long.
A laceration occurs when the skin is torn. Usually, lacerations are rough with uneven edges but can have smooth edges. Because of their tendency to be uneven, lacerations may take a long time to heal and may result in significant scarring. Occasionally, keloid tissue develops at the sight of the scar, which can be painful and disfiguring.
Puncture wounds occur when the skin is pierced by a pointed object or instrument. Punctures are usually deep and narrow. The depth of the puncture may inhibit healing or allow the entrance of foreign material into the body. Puncture wounds may also damage internal organs, leading to complications in healing, disability, or even death.
Abrasions occur when the skin is rubbed or scraped. The percentage of the body surface becomes an issue because of the likelihood of a secondary infection due to the openings in the skin. Scarring is also an issue with abrasions depending on how rough they are. Usually, abrasions heal with no permanency; however, severe abrasions can result in significant disfigurement on the face or hands. Abrasions are often seen when vehicle occupants are thrown, such as in motorcycle or bicycle accidents.
When evaluating injuries due to these types of wounds, the claims professional will want to consider several issues, including:
The degree of pain likely to be suffered
Whether the pain can be relieved through medication
The time required for healing
The amount of treatment that will be necessary
Treatment complications due to comorbidities
Whether the injured party is disabled during the treatment period
Location of the wound
The depth and length of the wound and area of skin involved
The cause of the bleeding
The use of sutures, how many, where, and type
The involvement of other organs or joints
Potential for infection
The likelihood of full recovery
The amount of time required to reach maximum medical improvement
Whether there will be any resultant disability
Potential for disfigurement
Placement of the disfigurement
Whether the disfigurement will result in a loss of wage-earning capacity, such as for a model or performer
Disability due to scarring
The existence of phantom pain or continuing pain after full recovery
By analyzing the effect of wounds in an objective manner, the claims professional is better prepared to accurately evaluate the impact of the wound to the injured party and the costs associated with treatment and recovery.
Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI.
Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion.
If such advice is needed, consult with your attorney, accountant, or other qualified adviser.