Expert Commentary

Evaluating Bodily Injury Claims—The Effects of Traumatic Injuries

Traumatic injuries are caused by accidental occurrences involving force. Traumatic injuries can include sprains and strains, fractures, lacerations, and other wounds, as well as debilitating injuries to the back or amputation of limbs. When considering the effects of a traumatic injury, it is important to keep in mind the concepts surrounding psychosomatic medicine—which considers the interrelationships between social, psychological, and behavioral factors in the healing process. Quality of life is an important factor for adjusters to consider when evaluating the effects of traumatic injuries, especially if the trauma results in permanent disability.


Personal Lines Claims
July 2013

A body that has been subjected to trauma may undergo significant change. There are two basic types of changes that can occur—structural change and functional change. Structural change refers to visible differences in the body following the traumatic injury. These can be visible to the naked eye, through use of X-rays or microscopic analysis, or as a result of lab tests. Fractures, amputations, and tumors would all be considered structural changes.

Functional changes refer to disease processes that alter how the body functions but do not change the structure of the body. Because of advances made in psychosomatic medicine, it is becoming increasingly clear that bodily functions can be disturbed beyond what would have been expected from the structural damage. Accidental injuries often include some element of fright or fear. Emotional feelings can impact the healing process so it is important for the claims professional to understand the impact of emotions such as fear, anger, or extreme worry and how they may extend the healing period.

Functional changes can cause structural failures, such as ulcers, vascular failure, and heart conditions. Without knowledge and understanding of these influencers, claims professionals may find it difficult to accept or comprehend the difficulties a claimant may experience if fright or worry following a traumatic injury exacerbates a preexisting heart condition or a neurosis or psychosis. These complications may also cause the treating physician to be reluctant in quantifying the healing period or even the extent of the disability. Structural changes are relatively easy to diagnose and treat. However, the impact of functional changes or conditions may cause a physician to qualify the patient's prognosis, which in turn may make it more difficult for the claims professional to accurately assess the extent of the healing period as well as the anticipated disability that is related to the accidental injury.

What Are Traumatic Injuries?

Traumatic injuries are wounds or disabilities caused by an external force. By contrast, congenital disorders, sometimes called congenital diseases, are maladies that exist at birth or before birth or may become apparent in the early days of childhood. Some congenital conditions become apparent following a disease or illness as a result of an infection.

Trauma can weaken the body and make it more susceptible to infections, which in turn, may aggravate a congenital condition. Claims professionals will want to consider this possibility when evaluating bodily injury claims with the traumatic injury being the catalyst for additional complications. So, while the primary injury may have been caused by the trauma, comorbidities will have significant impact on the length of disability, treatment plan, prognosis, and permanent disability, if any.

To adequately assess traumatic injury, the claims professional will want to obtain the following information from either the injured party or the treating physician (after execution of a medical authorization form by the patient).

The injury:

  • Detailed description of the injury itself
  • Objective evidence

  • Subjective complaints, including first manifestation and duration

  • Body parts involved

Initial medical care:

  • Treatment or care at the scene (first aid)
  • Whether rendered by professional emergency medical technicians or on-site medical personnel

  • Formal treatment at hospital emergency room or clinic
  • How transported from scene to treating facility

Ongoing medical treatment:

  • Identification of treating physician
  • History of treating this person

  • Identification of all assisting or referring physicians
  • Names and addresses, extent and purpose of treatment given

  • Dates of treatment, by whom, and for what purpose
  • If hospitalized, dates of inpatient service and any outpatient follow-up
  • Operations or casts—including treatment, dates of service

Recovery:

  • Prognosis for recovery
  • Disability or scarring anticipated

  • Ability to work during recovery period
  • Physical therapy required, dates, extent, modalities
  • Patient’s attitude toward recovery

Medical history:

  • Identification of prior medical conditions, illnesses
  • Treatment obtained in the past
  • Ongoing care and why necessary
  • Identification of all treating physicians and facilities such as hospitals, clinics
  • Preexisting disability
  • Family history of illnesses, diseases, or medical conditions

By obtaining complete information regarding the traumatic injury itself and treatment of the injury, the claims professional will begin to develop insight as to the extent of the direct care needed for the accidental injury. Other information, such as treatment plans and prognosis, will assist in evaluating the extent of the healing period. Family history is included in the investigation in order to determine whether there is a propensity for preexisting conditions that may not have been diagnosed in the patient yet but that may have a bearing on the prognosis and eventual recovery.

Conclusion

By gaining an understanding of psychosomatic medicine and the impact of emotions and the environment on the healing process, claims adjusters will be better prepared to evaluate traumatic injuries.


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.

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