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A tale of two claims

March 15, 2023
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“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness…"

Charles Dickens may well have had something there — even though he wasn't writing about workers' comp claims.

Wisdom in workers' compensation is rare, and even when we have it, we might feel too busy to digest it and and put into place. A quick comparison of claims might help employers see how important it is to know what to do — and do it immediately.

The two workers

Here is a tale of John and Mark, two construction workers who experienced the same injury at two different companies. Both men are 40 years old with ten years of seniority and earn $800 per week. Both men fell while climbing a ladder as they reached to grab shingles on the roof. They lost their grasp and began to fall, “jerking" their shoulders as they fell six feet, landing on their right shoulders. Both men immediately notified their supervisors about their injuries, and their respective companies immediately reported the claims.

And that's where the similarities end.


John works for ABC Roofing. Though he had been trained to work safely at heights, John chose not to tie down.

ABC Roofing had curated a designated medical provider list and gave John the corresponding designated provider letter. 

John was seen the same day at Occupational Care, one of the designated providers from the letter. Once treated, the physician gave him a work restriction to not use his right arm. When John's supervisor got the work restriction notice, he let John know the company could accommodate his restriction with modified duty, and he could report to work the next day.


Mark works for XYZ Roofing. His company did not offer safety training, and Mark did not tie down. (Even with safety training, Mark may have chosen not to tie down, but since his company didn't offer the training, he may not have known to do so.)

Here's where it gets interesting

XYZ Roofing did not give Mark a designated provider letter, instead telling him to go home for the day and rest.

Mark's day didn't go as smoothly as John’s. Later the night of the fall, Mark's pain was so bad, he went to the emergency room for treatment. Mark was placed off work and told to report to Dr. Fancy. After three days off work, Mark called his supervisor who told him they didn't have work that would accommodate his injury.

The treatment

Both men are referred for an MRI, which shows a rotator cuff tear.

John’s designated provider referred him to an orthopedic surgeon and continued to work on modified duty.

Mark, however, is still off work and hasn't heard from XYZ Roofing. He becomes so frustrated, he hires a workers' compensation attorney.

Both men’s doctors refer for surgery, which takes place on November 15. John begins on his lost wages benefits that same day; Mark continues on lost wage benefits.

Physical therapy starts for both men, and both are released to modified duty on December 15. ABC Roofing accommodates John the same day; XYZ Roofing tells Mark they can't bring him back until he can do his regular job.

John gets paid a total of four weeks of lost wage benefits at 50 percent of the wage replacement (because he didn’t follow his company’s safety training). Mark's lost wages at his full wage rate continue for an additional ten weeks while he recovers.

The final chapter

John finishes his final physical therapy appointment with Occupational Care and is placed at maximum medical improvement (MMI) on February 1 of the following year. He receives a 15 percent scheduled impairment rating on his shoulder, which equals $9,283.87. Impairment ratings determine how much an injured worker receives in cases involving permanent disability. In this case, John has a 15% permanent loss of function in his shoulder. His final admission is filed. His impairment rating is paid out, and John's claim closes the following March 1.

Mark, on the other hand, continues to complain of pain for an additional four weeks. His MMI is dated March 1, a month after John, and he also receives a 15 percent impairment rating for the same amount as John. His final admission is filed, but Mark and his attorney object to the admission. A Division Independent Medical Exam is done on the following April 15, which assigns Mark a 9 percent whole-person rating, which equals $26,356.

Simple steps to control claim costs

If you take away nothing else from these examples, please know that to keep your workers' compensation cost down, you need to:

  • Create a safety program — and enforce it
  • Provide a designated provider letter to injured workers
  • Develop a modified duty program – and offer it
  • Keep in touch with your employee when they are hurt

— and keep in touch with Pinnacol.

Safety services that can save lives and money

When shopping for a workers' comp insurer, it's not often you find a provider also eager to be a safety partner at no additional cost—that's why 56,000 and counting businesses choose us.

Our services go beyond great coverage by offering our customers free, expert safety services and a robust return to work program for injured workers.

Ready to work together to find ways to help improve business safety and decrease costs?

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Pinnacol Assurance assumes no responsibility for management or control of customer safety activities. Please ensure your business meets the requirements of all federal, state, and local laws, regulations, or ordinances related to workplace safety.

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