Back injuries are the most common musculoskeletal injury, and four out of five people experience back pain in their lifetime.¹ With 8% of these injuries resulting in chronic pain and long-term workplace absence,² it’s important for health insurance claim professionals to know about the different kinds of back injuries and their associated risk factors so they can manage these claims effectively.

Leaving aside traumatic injuries such as spinal cord injuries resulting in paralysis, back pain is usually mechanical in nature and occurs when components of the spine are disrupted. Injuries such as sprains and strains impact the ligaments, tendons and/or muscles supporting the spine causing the pain.

Additionally, degenerative changes to the spine and/or the intervertebral discs, as well as arthritis can occur with ageing. Progression of these changes depends on an individual’s lifestyle, occupation, and history of injury or disease. Neuropathic symptoms such as sciatica occur when the spinal cord or nerve roots are compressed, usually caused by disc disease and/or spondylosis.

Five important claims considerations

Claim professionals need to be mindful of several factors to ensure that a back injury claim is managed fairly, effectively, and efficiently. Claim validity should be determined not only by a medical assessment, but also for occupational and financial factors, in view of the terms of the policy. Fair and effective case management is not only about risk management; it also improves customer experience and overall outcomes.

Pre-existing Conditions

While some back injuries can occur because of an acute injury, back injuries are often caused by degenerative changes that build up over time, referred to as “wear and tear”. When assessing back injury claims, it is important to investigate symptom onset and mechanism of the injury, as well as any history of prior episodes. This ensures that correct policy eligibility checks are completed at claim outset.

Medical considerations

A clear diagnosis will assist with claim assessment and managing claimant expectations regarding treatment and prognosis. However, diagnosis alone is not sufficient to determine claim liability. Most disability policies require a level of functional impairment that is severe enough to render the insured from performing their occupational duties. Therefore, a good understanding of how the reported symptoms are affecting the claimant’s daily life and work ability is essential. This understanding can be gained by talking with the claimant, treating doctor(s), and/or referring for an external rehabilitation provider to complete a functional assessment.

Occupational considerations

Completing a thorough occupational assessment is crucial to determine claim validity against the definition of disability as outlined in the policy terms and conditions. An office worker with a sedentary role who has the flexibility to adjust their posture every 30 minutes and who could benefit from a phased return to work, may recover and achieve a full return sooner than someone who is employed as a brick layer and has less flexibility with their occupation, which requires heavy functional demands to perform their role. Reasonable adjustments and allowances should be made by the employer to facilitate a return to work by providing reasonable workplace accommodations to support employees with disabilities. The quicker someone returns to work the better the outcome for all parties involved.

Prolonged Absence from Work

Recovery depends on a variety of factors and can be prolonged by treatment delays, poor education, and limited provision by employers to support employees in returning to work. For those absent from work due to back pain, 68% return to work within 30 days and 86% return to work within one to six months.³ It’s important for claim professionals to understand what influences a claimant’s recovery and how we can help. Early intervention, for example, can assist a claimant to recover within the acute phase of the injury before the pain becomes chronic. Claim professionals need to remain mindful of self-employed claimants who may require additional assistance and advice on how to structure a phased return to work. More detailed information obtained at the beginning of a claim will allow the claim professional to manage the claim more effectively.

Returning to work

Engaging your internal rehabilitation team (if available) or referring externally to a qualified occupational rehabilitation provider can help claimants return to work within a timely and cost-effective manner. Possible scenarios in which this may be appropriate include when a claimant fails to recover within the anticipated timeframes, or when a claimant is experiencing symptoms secondary to their primary diagnosis such as mental health difficulties. It’s important that the rehabilitation specialist understands the insurance product, the claimant’s eligibility criteria and the wider market.

Back to basics

It is beneficial for claim professionals to stay up to date on common back conditions, the relevant medical terminology, the best treatment options, pertinent risk factors, and anticipated recovery timeframes. Understanding the full range of medical and occupational considerations will help them assess and manage claims more effectively and efficiently.

If back injuries are diagnosed and treated in a timely way, and the correct rehabilitation and workplace adjustments are provided, this can help claimants return to their pre-injury level of functionality in a safe and durable manner. Returning to work doesn’t result only in a claim termination, it also means that clients can regain their physical and financial independence, a renewed sense of purpose, and a better quality of life.

If you want to learn more about any of the claim considerations mentioned here, such as rehabilitation, diagnosis and treatment, contact a Gen Re representative and we will put you in touch with one of our specialists.

Endnotes

1. MD Guidelines, https://app.mdguidelines.com/health-advisor/mda%2Fback-pain (secured log‑in).
2. Ibid.
3. Ibid.