Case stories of workers’ compensation claims

Why did the insurance company refuse compensation? Why does the insurance company first agree to pay compensation, only to cease payment even as the sick leave continues?

The Workers’ Compensation Center has compiled case stories of workers’ compensation claims that involve ambiguities. Each story is a combination of several real-world cases. None of the stories are exact depictions of real events. The stories are presented on a visual timeline.

Case story of a pain syndrome caused by an injury

Complex regional pain syndrome is a long-term condition that causes local pain in a limb. It is characterised by changes in sensation and motor function and abnormalities of the autonomic nervous system.

“A, a customer service advisor, took part in a recreational event organised by the employer. During a group activity, A injured his left shoulder. The insurance company reimbursed A for medical examination and treatment expenses until August 2016 and later thereafter. A was also paid a handicap allowance.”

Timeline (in Finnish) for the case story about CRPS covered as an occupational accident 

Brain damage case stories

Brain damage is caused by a traumatic injury to the head. The symptoms of brain damage vary significantly in their severity. In most cases, the damage is minor and the patient recovers quickly. Assessment of the severity of brain damage measures the duration and severity of unconsciousness, length of the post-traumatic gap in memory, symptoms and findings detected in the examination of the central nervous system, and results of brain imaging studies (source: Terveyskylä/brain damage)

“V, a 45-year-old payroll administration expert, tripped on the stairs at work and suffered a brain injury. The insurance company reimbursed the examination and medical expenses, loss of income and work try-out. During the work try-out, V suffered another head trauma outside work. The insurance company refused to reimburse the examination and treatment expenses from the new injury.”

Timeline (in Finnish) for the case story about a brain injury covered as an occupational accident and a new head injury

“M, a 35-year-old HR employee, was on her way to work when a truck suddenly turned in front of her car. M suffered a brain injury, followed by rehabilitation and a work try-out. Later, M was able to begin working full time. The insurance company reimbursed the costs of the occupational accident.”

Timeline (in Finnish) for the case story about a severe brain injury covered as an occupational accident

Asthma caused by microbial growth - two case stories

Asthma caused by microbial growth due to moisture damage may be diagnosed as a occupational asthma when the diagnosis is made by a specialised medical unit and in accordance with Current Care guidelines (Käypä hoito). It is also important to demonstrate that the patient has been exposed to microbial growth caused by moisture damage to a significant extent, that the patient’s symptoms manifest and worsen in predisposing environmental conditions, and that there is a causal link between the patient’s symptoms and the environment that is provable with PEF monitoring of the workplace.

“H, a 35-year-old radiology nurse with no pre-existing conditions, was exposed to microbial growth caused by moisture damage at the workplace and contracted asthma. The insurance company deemed the condition to be occupational asthma and covered all incurred expenses and harm.”

Asthma caused by microbial growth - timeline (in Finnish) for the case story

“O, a 40-year-old kindergarten teacher, was hospitalised due to shortness of breath. He was diagnosed with asthma. After investigation, the insurance company found that O suffers from occupational asthma, but that the presence of symptoms in the renovated premises of the workplace were not due to an occupational asthma covered by the insurance.”

Asthma caused by microbial growth due to moisture damage, symptoms not caused by occupational asthma: timeline (in Finnish) for the case story

Case story of farmer’s lung

Farmer’s lung or allergic alveolitis is most commonly caused by handling mouldy hay, straw and sawdust in farm work. Its symptoms include shortness of breath, cough and fever, which usually manifest four to eight hours after exposure to mouldy dust.

When assessing whether or not farmer’s lung constitutes an occupational disease, it is essential to know whether exposure to mouldy dust took place during work. If farmer’s lung is caused by work-related exposure, it is covered as an occupational disease.

“M, a 76-year-old farmer, retired after 40 years of work. After this, he began experiencing respiratory symptoms, which were later diagnosed as farmer’s lung. At first, the insurance institution did not classify the illness as an occupational disease, but later agreed to cover the costs.”

Farmer’s lung as an occupational disease - timeline (in Finnish)

Case story of a knee injury

The knee joint is formed by the joints between the thigh bone and shinbone and the thigh bone and kneecap. The knee is easily injured and damaged by various strains and blunt trauma. As a load-bearing joint, it is also prone to degenerative diseases. A minor strain or blow to a worn-out knee joint can cause a difficult spiral of complications, even when no previous symptoms were present.

“A, a 55-year-old construction worker, stepped into a pothole while on the way home. In the fall, he strained his knee. The insurance company reimbursed the medical expenses for the strain but refused to cover the costs of the diagnosed osteoarthritis.”

To the timeline (in Finnish) for the knee injury case story

Case stories of shoulder injuries

The shoulder is the most mobile joint in the human body. The shoulder is surrounded by the rotator cuff, a group of several muscles and tendons that is prone to tearing; for example, when falling on the extended arm or as the result of some other intense force. After a partial rotator cuff tear, the shoulder may recover from all symptoms. In most cases, a fully torn rotator cuff requires reconstructive surgery.

The shoulder is also prone to degenerative diseases. Although fairly common, these disease-based damages are not covered by accident insurance, as the insurance company is only liable for reimbursing the costs of accidents.

Shoulder injury case story 1 (Opens the timeline (in Finnish) for the case story to a new window)
“The slippery conditions in March took their toll. H, a 42-year-old janitor, slipped in the yard of his place of work and injured his shoulder. The janitor, H, took sick leave..”

Shoulder injury case story 2 (Opens the timeline (inFinnish) for the case story to a new window)
“P, a 60-year-old production worker, tripped and fell while at work and injured her left thumb and shoulder...”

Shoulder injury case story 3 (Opens the timeline (in Finnish) for the case story to a new window)
“R, a 58-year-old secretary, was reaching to pick up a heavy folder when it slipped from her hand and fell on the floor. R stumbled and felt pain in her shoulder. The shoulder did not heal as expected...”