Scenario 1: The accident occurred late at night on a weekend from a single vehicle collision resulting in significant injuries. This raises red flags about a potential alcohol-related incident. Key steps would be to get a full statement, investigate the late reporting, obtain medical records and employment records, and determine if the claimant was eligible for benefits. Scenario 2: The claimant suffered major injuries requiring two prosthetics. Payment priority would be the individual's extended health coverage first, then the spouse's, and lastly accident benefits. The claimant would likely be eligible for benefits through Alberta given it was a no-fault accident in another state. Scenario 3: A worker claiming benefits after falling on ice during a coffee break would likely be

1. Work Sample
Prepared by Susan M. DeVore
Compilation of Pre-Interview Assignments
2010 / 2011

2. Scenario 1:
The accident occurred November 1, 2010 (reported December 1, 2010). This is a
single vehicle accident occurring at 2:00am on a Saturday, and the driver (and sole
occupant) of the vehicle sustained significant injuries including a fractured pelvis,
WAD II, and significant facial abrasions and lacerations. The client’s mother has
contacted us to advise of the accident and notify us that the injured party has been
unable to work since the accident (the client is employed as a waitress), and is still
hospitalized.
Questions:
a. What things would you consider when reviewing this file with the claims
representative on your initial discussions?
RED FLAGS: Late reporting of the accident, the time 2 AM and the day
Saturday, single vehicle collision – this potentially smells of an alcohol related
collision and thus would exclude the Insured from any Weekly Indemnity
Benefits should she be convicted of same. Further, the Insured’s occupation,
waitress, if she does not declare her tips on her Income Tax returns then, she
would not be able to include the tips in her gross weekly earning.
I would suggest the following courses of action:
• First and foremost, obtain a Non-Waiver Agreement from a/o provide
a Reservation of Rights letter to the Insured due to the delay in
reporting this loss;
• Attempt to obtain a full Statement from the Insured;
• Find out why the loss was not reported sooner;
• Secure executed Authorizations for Release of Information upon
behalf of the Insured so that medical and wage loss information can
be obtained.
• Perhaps contact Underwriting and obtain a copy of the original
Application for Insurance for review and be certain that all
underwriting criteria were met;
Obtain a copy of the Police Report to determine how the loss occurred
and if any charged were laid against the Insured (especially impaired
driving, driving over the legal limit et al) as well as to be certain the
Insured was alone, seat belted;
• Obtain a copy of the Insured’s driver abstract to determine if she had
any previous impairer’s a/o other convictions we should have been
aware of;
• Procure copies of the Insured’s work schedule, employment records,
maybe even tax returns as being a Waitress had she not declared her
tips on her Tax Returns she would not be entitled to include same as

3. her part of her total income for purposes of calculating Weekly
Indemnity Benefits;
• EMS records as well as Admission Records would be beneficial;
b. What reserves would you recommend the claims representative posting
and why?
As for Medical Expense reserves I would recommend a reserve of $30,000.00
due to the relative severity of the injury sustained by the Insured and the
potential residual squeal thereof ie: likely the Insured will require much
physical therapy, perhaps some medical apparatus including a walker,
crutches once she is ambulatory and perhaps even some nursing assistance
once at home*.
With respect to the Weekly Indemnity component of this claim, I would
recommend a precautionary reserve (until exclusions have been ruled out) of
$16,640.00. This amount is based on an average hourly wage of $10.00 and a
40-hour work week (ie: $10 x 40 hours = $400.00 per week less 80% =
$320.00 x 52* weeks = $16,6400.00). I believe that working with averages is
a safe assumption until concrete information can be provided.
• (Lack of information ie: open or nondisplaced pelvic fracture
definitely factor into recovery time and rehabilitation modalities. I
am working on the assumption that this was a nondisplaced pelvic
fracture which has an average of bone healing of 6 to 12 week;
however, bone strength and the ability of the bone to withstand a
heavy weight-bearing could potentially take up to one year for
complete recovery. Six to 12 months of recovery time is generally
recommended before returning to heavy work. Further, on average,
physical therapy could range from 24 visits for up to 16 weeks.)
Scenario 2
A policyholder is involved in a loss in the U.S. (in a state that allows Accident benefits
subrogation) this was a head on collision, in which our client was found not a fault for.
Our client has extended healthcare benefits with sun life, and his spouse also has
extended healthcare benefits with Great West Life. Our client has suffered significant
injuries and his right arm and right leg have been amputated. Our client’s counsel has
requested that we pay $150,000 for the 2 prosthesis required.

4. Questions:
c. What would you consider when reviewing this loss?
Severity of injuries.
It would be prudent to obtain a copy of the State’s Auto policy for
informational purposes.
Extended healthcare benefits held by the Insured and his spouse.
Subsection 1 (3) – Section B Medical Benefits (SPF 4)
Insurance Act of Alberta, RSA s. 619, 629, 631, 641
d. What is the priority of payment?
1. Utilization of Extended HC Benefits of the Individual’s whose
DOB is the earliest;
2. Followed by exhaustion of the Extended HC Benefits of the
eldest;
3. Section B Medical Benefits.
e. Is the client eligible for Accident benefits coverage from Alberta or the
State they were in?
From my review of the Question posed, there is no indication of “No-
Fault” benefits through the State, only Accident Benefits Subrogation thus
it would appear that once both extended healthcare policies have been
exhausted, then the Insured would be entitled to Alberta Section B
Benefit. Alberta Section B Benefits would then sought out from the State
(ie: subrogation).
Scenario 3
A worker walks across the street on his coffee break for a chocolate bar and falls on the
ice in the 7-11 parking lot and breaks his femur. He submits a worker’s report and claims
for compensation benefits. (policy information attached).
How would you adjudicate this claim file?
1. Review the Employer’s Report of the incident;
2. Review the Worker’s Report of the incident;
3. Review the Physician’s Report, if available, upon receipt of the claim;

5. 4. However, upon noting the location and circumstances of this incident, it is this
writer’s opinion that the claim be DENIED on the following grounds:
• Location: the incident did not occur on the Employer’s premises (“the
worksite”) nor did it occur as a result of the Worker’s employment duties;
• The Worker removed himself from the scope and course of his
employment at the time of the incident for purely personal reasons;
• The Worker chose to leave the worksite, of his own accord, and not under
the direction of his Employer either directly or indirectly;
• The Worker was crossing onto other public property and not that of the
Employer’s.
Unfortunately, in this instance, the Worker was the author of his own demise. Although
the Worker sustained a very unfortunate and serious injury, there is no “liability” on the
part of the Employer or WCB to initiate a claim.
Scenario 4:
Describe what factors you would use in assessing fitness for work?
In assessing a Worker’s fitness to return to work, medical evidence would be the most
salient factor to be relied upon. For example, has the Worker’s Physician, Therapist’s,
Specialist’s et al given the green light to the worker to return to his pre-injury working
capacity? Has the Worker plateau'd in his recovery (ie: he is not going to get any better
nor is he going to get any worse)?
Perhaps there may be some residual sequelae from the injury and the Worker would be at
risk of re-injury. However, he is not completely and total incapacity from performing
certain duties. It might be prudent that a return to light or modified duties may be of
benefit to the Worker and the Employer. Cost effective for both parties and the Worker
can, within a reasonable time period, return to his pre-accident capacity.
What is the Worker’s Functional Capacity – does he need to be sent for assessment? Is
the Worker even capable of returning to his former employment, is re-training in order?
This is a difficult question to answer as a Worker’s return to work is dependent upon
many variables but mostly the injury itself – is it a fairly minor injury, a serious injury or
a catastrophic injury? Thus, the possible factors in assessing a Worker’s fitness to work
are enumerable.
Bottom line, in my humble opinion is Medical Evidence.

6. 4. However, upon noting the location and circumstances of this incident, it is this
writer’s opinion that the claim be DENIED on the following grounds:
• Location: the incident did not occur on the Employer’s premises (“the
worksite”) nor did it occur as a result of the Worker’s employment duties;
• The Worker removed himself from the scope and course of his
employment at the time of the incident for purely personal reasons;
• The Worker chose to leave the worksite, of his own accord, and not under
the direction of his Employer either directly or indirectly;
• The Worker was crossing onto other public property and not that of the
Employer’s.
Unfortunately, in this instance, the Worker was the author of his own demise. Although
the Worker sustained a very unfortunate and serious injury, there is no “liability” on the
part of the Employer or WCB to initiate a claim.
Scenario 4:
Describe what factors you would use in assessing fitness for work?
In assessing a Worker’s fitness to return to work, medical evidence would be the most
salient factor to be relied upon. For example, has the Worker’s Physician, Therapist’s,
Specialist’s et al given the green light to the worker to return to his pre-injury working
capacity? Has the Worker plateau'd in his recovery (ie: he is not going to get any better
nor is he going to get any worse)?
Perhaps there may be some residual sequelae from the injury and the Worker would be at
risk of re-injury. However, he is not completely and total incapacity from performing
certain duties. It might be prudent that a return to light or modified duties may be of
benefit to the Worker and the Employer. Cost effective for both parties and the Worker
can, within a reasonable time period, return to his pre-accident capacity.
What is the Worker’s Functional Capacity – does he need to be sent for assessment? Is
the Worker even capable of returning to his former employment, is re-training in order?
This is a difficult question to answer as a Worker’s return to work is dependent upon
many variables but mostly the injury itself – is it a fairly minor injury, a serious injury or
a catastrophic injury? Thus, the possible factors in assessing a Worker’s fitness to work
are enumerable.
Bottom line, in my humble opinion is Medical Evidence.