Self-inflicted long bone fractures for insurance fraud.

Self-inflicted fractures simulating traffic accident represent a new social fraud opportunity for criminality. Recognising scams through an increase of awareness of existence of self-inflicted arm fractures for insurance fraud could help community health workers to report these injuries to the competent authorities. In this article, authors have recognised an unusual but consistent pattern of upper and lower limb fractures whose incidence does not coincide in numerical terms with what is reported in literature. The aim of the present study is to describe fracture patterns observed over the past 2 years. Further, authors describe clinical presentations of these fractures and attempt to define a possible mechanism of these types of injuries.

Proving whiplash injury cases in court.

Car accident victims commonly report cervical spine distortion as their injury. Problems with proving this kind of injury, including its effects, come to light in insurance claims adjustment, and if the tortfeasor driver or the insurer refuses to pay compensation or general damages, such problems should be resolved in court. This paper discusses legal issues involved in proving whiplash-associated disorders under the law as it stood before 7 November 2019 and after the rules of civil procedure were amended.

[Prerequisites for a convincing (neuro-)urology opinion : Importance of objectivity in the legal sense of full proof, occurring under duty of compliance of the surveyed person]. / Voraussetzungen für ein überzeugendes (neuro)urologisches Gutachten : Stellenwert der Objektivierung im Sinne des Vollbeweises unter Mitwirkung(spflicht) des Probanden.

Convincing urological expert opinions require the objectification of medical history complaints of health and functional disorders in the legal sense of obtaining full proof. This means that there is such a high degree of likelihood, beyond any doubt of a reasonable person observing the condition (Bundessozialgericht Entscheidung [BSGE] 32, 203/207). This requires a comprehensive general and special medical history survey, as well as a series of urological examination procedures in the hands of experienced urologists. In addition, it is necessary to observe the fundamentals of the various legal areas, from which the opinion order comes from, without exception. However, it would not be possible in all cases to achieve an unequivocal clarification of the problem in question. Nevertheless, it should be ensured that the best possible approximation to the actual truth of the case is reached. In this way, the democratic fundamental right of all the appraised persons to equal treatment could be met in the best possible way and optimal support to the commissioning institutions would be made available.

[Medical Knowledge in Accident Insurance : Assessing "Pneumatic Tool Damages" at the Bergmannsheil Hospital, 1929-1944]. / Medizinisches Wissen in der Unfallversicherung : Die Begutachtung von "Preßluftschäden" im Krankenhaus Bergmannsheil, 1929­1944.

The article focuses on one central element of medical activity in the context of the German social insurance system: providing expert assessments in accident pension cases. Taking an example from interwar coal mining, it aims to reconstruct how social policy makers first conceived of "pneumatic tool damages" as occupational disease and how trauma surgeons had to deal with this new entity of social law once it had been institutionalized in 1929. Drawing on physicians' publications as well as archival sources from the supreme court in social insurance, the Reichsversicherungsamt, the article examines how the controversial generation of new knowledge took place. It argues that medical knowledge was neither simply applied to administration and law nor was it compromised by the necessity to adjust it to those fields of decision-making. Expert medical opinions should instead be understood as a specific form of medical knowledge.

[The German Statutory Accident Insurance: A successful example of a value-based healthcare structure]. / Die Gesetzliche Unfallversicherung in Deutschland als erfolgreiches Beispiel einer Value-based- Healthcare-Struktur.

In the mid-1920s Porter and others developed a reform approach for existing health care systems, aiming at a patient-focused, value-based orientation. Improving patient outcomes by attaining, preserving and restoring good health is inherently less costly than dealing with poor health. The authors of the present article will outline that the German statutory accident insurance system, which was already introduced in1884 and is of an evolving nature, reflects key elements of Porter's efficient value-based health care system. The German accident insurance system with its statutory mandate limited to the prevention and rehabilitation of work-related damage to one's health can also serve as a model for other larger health care insurance systems. Prevention and rehabilitation is pursued using all appropriate means to achieve the set goals of protecting and restoring individual health. In line with these objectives, the statutory health insurance controls the process in terms of the required care quality. The components of a complex health care system, usually managed by a variety of different institutions, are consolidated. Thus it can be ensured that in both prevention and rehabilitation all services that are necessary to keep focussing the value "individual health" rather than indemnities are applied.

[Expert Assessment of Traumatic Disc Herniations]. / Gutachtliche Beurteilung des traumatischen Bandscheibenvorfalls.

In numerous legal areas, expert assessments are needed to clarify the causality of herniated discs: Was the damage caused by an accident? The literature mentions specific requirements regarding the trauma mechanism as well as temporal criteria, which prescribe the causality test. These are essentially high-energy traumas with immediate functional impairments. Accident-related MRI examinations are of paramount importance in the expert assessment process to confirm the primary body harm. In examining the causality constituting liability, competitive causes must be assessed. Since the legal requirements of the causality test differ in civil and social law, legal norms need to be taken into account. We present a test scheme that supports the assessment process through entry, implementation and decision-making levels.

[Reorientation of Medical Procedures Covered by Statutory Accident Insurance]. / Neuausrichtung der Heilverfahren der Gesetzlichen Unfallversicherung.

As of 01/01/2014, the German Statutory Accident Insurance (DGUV) has reorganized inpatient medical procedures. The central element of reorientation is the reorganization of the catalogue of types of accidents and type of medical procedures of hospitalized injured patients in 3 care stages. In addition, the reorientation also concentrates on hospitals with the highest performance and the best qualification and also focuses on severe and most severe injuries.This reorientation is also based on the White Paper of the German Society for Trauma Surgery (DGU), especially on the Trauma Network DGU. The new regulations will be implemented by the state associations of the German Statutory Accident Insurance.The hierarchy of care depends on established admission criteria and the severity of injury. This structuring also refers to special competence in the field of rehabilitation and will lead to the strengthening of multidisciplinary rehabilitation management and workplace-related modules of the healthcare. Overall, the accident insurance institution will place increased demands on their network partners.

[Prognostic assessment in private healthcare insurance part 2 : Risk supplement for accidental endoprostheses]. / Prognosebeurteilung in der Privaten Unfallversicherung Teil 2 : "Risikozuschlag" bei unfallbedingten Endoprothesen.

After examining the causes of an accident the medical expert working in the area of private health care insurance under the general accident insurance (AUB) sample conditions must ascertain incapacity within a period of time that has been contractually agreed between the parties involved. In addition, this must also state their position on the question as to whether there may exist any circumstances up to the latest possible point in time in insurance terms that would comprise an adequate prognosis of a future change in the long-term condition. This requires a high probability. In contrast to scientifically based findings serving as a prognosis of osteoarthritis, in the case of endoprostheses forecasts can only be based on medical experience, which in this case has to satisfy the standard of proof of a high level of probability, since necessary replacement operations after insertion of a prosthesis are sufficiently probable. The prosthesis supplements that have been applied to date in the context of an assessment of prognosis have their justification. In applying them, however, it must be considered on one hand that this supplement is comprised of an equally weighted proportion for future risk and on the other hand a preventive portion. This increases in significance with different prostheses on one and the same limb.

[Prognostic assessment in private healthcare insurance part 1 : Risk of osteoarthritis]. / Prognosebeurteilung in der Privaten Unfallversicherung Teil 1 : Arthroserisiko.

After examining the cause of an accident the medical expert working in the area of private health care insurance under the general accident insurance (AUB) sample conditions must ascertain incapacity within a period of time that has been contractually agreed upon between the parties involved. In addition, this person must also state their position on the question as to whether there may exist any circumstances up to the latest possible point in time in insurance terms that would comprise an adequate prognosis of a future change in the long-term condition. This requires a high probability.The sole risk of the evolution of the functional deficit arising from a proven or prognosticated post-traumatic osteoarthritis is excluded from this standard of proof which means that flat-rate risk supplements are not suited to this individualized approach and thus do not apply.

[The new treatment procedure of the German statutory accident insurance: From the perspective of a community hospital]. / Die neuen Heilverfahren der DGUV: Aus der Sicht eines Städtischen Krankenhauses.

The requirements of the German statutory accident insurance (DGUV) for the new treatment procedure were presented on 1 January 2013 in a new catalogue. The implementation of the certification of hospitals for the very severe injury procedure (SAV) by the DGUV should have been completed by 2014. These requirements placed high demands on trauma-oriented hospitals because of the high structural and personnel prerequisites. The background to the new organization was the wish of the DGUV for quality improvement in patient treatment in hospitals for patients with very severe occupational and occupation-related trauma by placement in qualified centers with high case numbers. No increase in income was planned for the hospitals to cope with the necessary improvements in quality. After 2 years of experience with the SAV we can confirm for a community hospital that the structural requirements could be improved (e.g. establishment of departments of neurosurgery, plastic surgery and thoracic surgery) but the high requirements for qualification and attendance of physicians on duty are a continuous problem and are also costly. The numbers of severely injured trauma patients have greatly increased, particularly in 2015. The charges for the complex treatment are not adequately reflected in the German diagnosis-related groups system and no extra flat rate funding per case is explicitly planned in the DRG remuneration catalogue. The invoicing of a center surcharge in addition to the DRG charges has not been introduced.

[New regulations for inpatient treatment of the statutory accident insurance: From the perspective of a university medical center]. / Neuordnung des stationären Heilverfahrens der Gesetzlichen Unfallversicherung: Aus Sicht einer Universitätsklinik.

BACKGROUND: New regulations of the German statutory accident insurance for inpatient treatment have been introduced. The aims of the new regulations are to improve cost-effectiveness and the quality of medical care. The introduction of the injury type catalogue and the severe injuries type procedure (SAV) has led to a concentration of resources. The purpose of these innovations is an increase in the quality of treatment of patients with complex injuries. CONCLUSION: The introduction of the new regulations resulted in a centralization of medical care in order to optimize the quality of treatment of complex injuries from occupational accidents. Hence, the high demands concerning infrastructure and human resources expected of a level one university medical center are taken into account.

[Aspects of expert opinions of avulsion fractures]. / Gutachtliche Aspekte von Apophysenschäden.

The apophyses as secondary ossification centers are connected with the bone by cartilage. During the growth phase of puberty, the apophyseal plate is a mechanical weak spot. Especially, apophyses in the hip and pelvic area are exposed to considerable tensile and sheer stresses due to the strong muscles which are inserted here. The frequency of injuries to the apophyses correlates with the extent of sporting activities. For athletes participating in "Youth Train for the Olympics", this is the most common injury of all. Most often, the apophysis of the rectus femoris muscle is affected at the anterior inferior iliac spine. In adults, after complete ossification of the apophyseal plate such injuries are rare. However, in a very unusual mechanism of injury with maximum forced hip flexion and simultaneous maximum knee extension, avulsions of the ischial tuberosity are observed in adults. During the causality test-especially in the legal area of statutory accident insurance-the question is always whether the alleged course of events has to be regarded as a legally significant (partial) cause or if a longer period of time has been involved, so that the resulting morbid apophysis detachment was predominately due to fate, in which the alleged event must be interpreted as legally immaterial.

[Causal Participation in Accident Assessment]. / Zur kausalen Mitwirkung in der Unfallbegutachtung.

A variety of different factors may participate in causing an accident or in influencing its course. These have different legal consequences in different areas of insurance. These differences are outlined for the assessment areas, together with the different states of evidence. In particular, it is discussed whether and under which conditions a trauma can indirectly (as a participating factor) either cause, trigger or exacerbate detachment of the retina.

[Principles of intervertebral disc assessment in private accident insurance]. / Grundlagen der Bandscheibenbegutachtung in der privaten Unfallversicherung (I).

Due to the spread of intervertebral disc degeneration, insurance companies and experts are regularly confronted with related assessments of insured persons under their private accident insurance. These claims pose a particular challenge for experts, since, in addition to the clinical assessment of the facts, extensive knowledge of general accident insurance conditions, case law and current study findings is required. Each case can only be properly assessed through simultaneous consideration of both the medical and legal facts. These guidelines serve as the basis for experts and claims.managers with respect to the appropriate individual factual assessment of intervertebral disc degeneration in private accident insurance.