by rmrolley » Fri Mar 13, 2009 06:25 am
'm dealing with an unfamiliar situation, and would appreciate any useful advice from those of you who have been in my shoes before. In September 2008, i was involved in a significant auto accident. I was traveling at approximately 40mph, when a car pulled out of a private drive into my path. I had no time to stop, and the end result was a T-bone accident. Damage to my car was approximately $4000. I had my wife, and two children in the car ages 3 and 4. I went to the emergency room with head, neck, and shoulder pain, and was examined by the ER physician who after a series of x-rays, and a CT scan of my head and neck, diagnosed me with a moderate to severe cervical strain, and advised me to follow up with a spine specialist. 3 days later, I was examined by an orthopedic spine surgeon, who ordered his own imaging studies. He agreed in part with the ER doc, but also diagnosed bulging discs at the c5-c6, and c6-c7 levels. He gave me pain meds, muscle relaxers, and steroids, and advised me to not engage in any strenuous activity. I had several follow up appointments, and in about 6 months I was finally pain free. I was referred to another orthopedist for my shoulder/arm pain, and after an MRI, was diagnosed with a torn labrum, humeral head contusion, partially torn supraspinatus tendon, a mildly seperated AC joint, and a brachial plexus contusion. We opted to treat with the conservative approach first, including therapy, medication, and even arthrocentesis (injecting the joint with a steroid/anesthetic combination). After 6 months of treatment, with no significant improvement, my doctor said I would need an operation to fix the problem, and relieve my symptoms (pain, impingement, and the clicking/popping in the joint). I had the surgery last week which to my understanding was actually 2 procedures. Right shoulder arthroscopy with debridement, and also a sub-acromion decompression. I have 8 weeks of physical therapy and rehab ahead of me, and will have missed over a month of work. This whole thing has caused me an significant amount of pain, anxiety, stress, etc, and has also prevented me from performing necessary daily activities such as taking care of my kids, bathing/dressing myself, driving, etc. The injury was to my dominant arm, and is immobilized for the time being. I have been receiving calls from the at fault driver's insurance company, essentially asking me to settle for less than I believe I am entitled to. I have approximately $30k in medical bills so far, as well as the $4000 damage to my car, $400 for a rental, and $6k in lost wages and counting. I am considering hiring an attorney here, but before I agree to hand someone 33% of the money that I've suffered for, I was wondering if anyone has any good info, or useful tactics I can use to try to resolve this with the insurance company on my own. I have asked them to disclose the policy limits for their at fault driver, but they refuse to do so. I don't want to give an attorney 33% especially if the guilty party only carries the minimum liability coverage. What formula do these companies use to place a value on claims? Or more importantly, does anyone have a ballpark estimate on what this claim may be worth? I'm just about 100% sure that its worth more than the $50k they're claiming is their "maximum authority". I'm going to have more than $50k in bills by the time this is said and done! I would greatly appreciate any input that any of you fine knowledgeable folks may have to offer. Thank you in advance for any pearls of wisdom.
Posted: Mon Mar 16, 2009 05:24 am Post Subject:
It’s great you have health insurance and yes, the auto insurance carrier will base your settlement off of total charges and not the contracted discounts between your doctor and health insurance. Is your health insurance aware that your medical bills accident related? Have they sent you a right of subrogation letter? If they are not aware, you need to let them know as soon as possible, as they are going to want to recuperate their payments. You don’t want a surprise letter from them, once they figure out that they paid for auto accident related injuries, and they are looking for money from you.
It sounds like you are under control as far as your recovery and have plenty of time to wait and see what happens. Lori addressed your question as to asking again about policy limits and how it may effect your UIM claim. If 50K is not their limits, they most likely won’t tell you what the limit is and frankly it really doesn’t matter. Your treatment is going to be what it is and knowing their limits (if higher then 50K) should not change your treatment to get better.
Posted: Mon Mar 16, 2009 11:07 am Post Subject:
First off, I'm glad you aren't going to settle until your are done..
do I continue to attempt to get him to reveal the BI limits, or do I just forget about this guy until I'm ready to start talking business?
I would still call and inquire about it, he should've told you if this was the case, but all won't I would tell him I just realized I have UIM and what that coverage is for so you want to put your company on notice if you need to file a claim with them under your UIM coverage...see if he will tell you the limits ...or if he will say he thinks his insured has adequete limits to handle your claim. Ask that as well...also ask if he got his 'authority' raised, if not you need to talk with his supervisor because although you are not ready to negotiate a settlement you do know that 50k is no where NEAR what you have in mind as fair...I know that the probability of future issues arising from the operation are greater than 40%. Permanent scarring and adhesions inside the joint, as well as visual scarring on the outside of the body, arthritis, and the potential for further debridement are among the most common.
That's just what I figured...be sure and get that info from your surgeon and tell him the carrier will likely request a report from him re: same, (future treatment/disability etc)...His diagnosis was a severe strain of the anterior longitudinal ligament, and spondylotic changes of the c5-c6, and c6-c7 discs/vertebrae. He said this condition could potentially result in a degenerative condition of those levels years down the road, possibly requiring surgery. We both agreed that operating and fusing my neck at the age of 30 wasn't even an option right now lol. I'll take my chances on that one!
I know all too well about this (personally)...make sure the carrier understands this as well..(mine are much worse than yours appear to be and have informed doc...I'll have the surgery when I cannot get up at all! :wink: )...I DO carry med pay coverage, however the limits for it are very low at $5k
Great! call your carrier and get a med pay (and possible UIM) claim filed, 'most' states allow double dipping of medpay re: you can collect it from your carrier and the at fault carrier..med pay is subrogatible in some states not in others but that won't affect you anyway...and no you cannot be rated up for it (my state atleast you might check your states dept of ins to be sure but I'd bet you cannot)...In figuring my meds damages, I used the amounts that the providers actually billed for, and not what was paid by the plan. Is this acceptable, or do I use the amount that my insurance company (aetna) actually paid?
No, you did fine that's exactly what I would have done...your health carrier WILL likely subro their payments...you will pay them back from your settlement...if they haven't mentioned or ask about this...you should find this out..or read your coverage, either way do not spend 'that' part when you get it until you know for sure...most if not all health ins companys will subro on an auto accident...Personally I feel like using the negotiated reduced figure wouldn't be an accurate representation of the seriousness of my injuries, and I'd be setting myself up for a significantly lower settlement. I feel that whatever price I (or my insurance company in this case), negotiates with my health care providers is really between us
I agree with you totally and Nationwide cannot ask (i don't think) what your health carrier has paid..that's your deal...Again, maybe I'm wrong here, but Nationwide had their chance to pay my bills starting 6 months ago when asked to, and they refused.
In all fairness NO bodily injuries are paid (not one penney) until settlement, if they didn't tell you that in your first conversation they should have...My biggest fear here is that I know that I'm never going to be back to 100%. I don't want to have to tell my son in 2 or 3 years that daddy cant show him how to throw a baseball or swing a bat because I wont be able to use my arm in that way
I totally understand that...and make sure you put that in your counter offer letter...and talk with the docs too, about what YOU can do to make sure that doesn't happen..Everyday all I do is sit around and think about all the "what ifs", and its pretty scary
I totally get that to...I'm returning to work to day after a 5 week abscense due to sugery and set backs...it gets very depressing, and i think makes you more tired and hurt more...MAKE yourself take a couple of walks a day...learn to rake leaves with that left arm...etc...you get the point...We're here to help in anyway we can...please don't hesitate to ask anything...some time takes a day or two but we always get back with you....
please don't forget to get that medpay filed today and get that 5k in your pocket ! (they can pay it immediately once they have the bills)...once you talk with the ADJUSTER from your company not your agent, mention to them you may have a UIM claim and can they help with finding out the policy limits of the other driver..
Hang in there hopefully you can get this wrapped up within the next 30-60 days....
Also be sure and as your surgeon if after all the PT he see anticipated ANY permanent disability to that arm even 10% (again the adjuster will need to know this and so do you for negotiating reasons)...Keep us in the loop and let us know what we can do to assist you...you have some 'homework' to do today now.. :wink:
Das is correct (of course)
If they are not aware, you need to let them know as soon as possible, as they are going to want to recuperate their payments. You don’t want a surprise letter from them, once they figure out that they paid for auto accident related injuries, and they are looking for money from you
But do NOT let them send a subro letter to Nationwide tell them to send it to you...if they send it to Nationwide, that is what nationwide will pay...and no they won't pay you the balance of what was charged...just insist you will be liable for their subro demand, and will pay it to them yourself..you might want to read your contract if you haven't got a letter from them yet...I've personally never seen a health carrier that did not subro these types of claims but i guess it's possible..One more question, (I'm too lazy to look it up :roll: ) what are the min. state requirements in your state ? (limits BI )
Hang in there you are in my prayers...
Posted: Mon Mar 16, 2009 08:40 pm Post Subject:
$12,500/25K. $7,500. for property damage.
Lori, their health insurance might have missed the auto accident. They shouldn't have, but it does happen. I worked health insurance for a while and sometimes accident claims wouldn't get caught till towards the end of treatment. At that time an accident letter or subrogation rights letter went out to the insured. I worked for a small TPA which didn't always have the staff to pursue for minor bills (we would have pursued this one), but I would assume that Aetna is large enough to pursue all subro.
Posted: Mon Mar 16, 2009 10:07 pm Post Subject:
It must be our health carrier thur husband's work (united health care) man I swear you can't have any treatment without getting a letter from them asking if there is ANY other insurance.. :lol:
12,500/25K. $7,500. for property damage.
WOW with manditory limits that low 50k just might be their limit! :shock:Posted: Tue Mar 17, 2009 12:36 am Post Subject:
Hi guys, it was a busy day for me! I went to my first followup visit with my surgeon today. He said I'm right about where I should be in the recovery process. The shoulder is a little more swollen than he anticipated, so I was sent home with the arm still immobilized with a prescription for a heavy duty anti inflammatory. Light PT begins Friday. When I got home I called my auto insurance company (21st Century), and updated them on whats going on. I did report the accident to them the day it happened, but didn't report a claim through them at the time. They said they will contact Nationwide and attempt to obtain the policy limits to determine whether or not we need to proceed with the UIM claim. I made copies of all of my bills so far, and its going in the mail tomorrow to get the med pay portion taken care of. As far as subrogation from Aetna, I did call them as soon as I started using my coverage to cover the treatment. 2 weeks later I received a letter from an outside agency called The Rawlings Company, who apparently handles their subrogation cases. I filled it out, and mailed it back, and that was the last I've heard of it. That was almost 2 months ago now.
For now, it looks like another 4 weeks in the sling aside from my twice weekly visits to PT. I go back to see the doc on April 13th. Can any of you guys recommend any good movies out on DVD??? LOL I've already watched every pay per view movie my cable company has to offer, ya think nationwide will pay my cable bill while I'm laid up? ;) Wishful thinking I know! Hopefully 21st Century is able to get an answer for me, but as you said, it really doesn't matter since I have several weeks of treatment/healing ahead of me. Thanks again for all of your input. It's much appreciated. I will keep you guys posted on any new updates/details.
Posted: Tue Mar 17, 2009 04:22 am Post Subject:
Lori, UHC is really bad about sending a letter for everything (I had them at one time). Some examiners get lazy and don't send them when they should. I know where I worked, every time the diagnosis came across as a 900 code (accident) we were supposed to send a letter. I would try and use common sense on some of them and not send the letter, and would always get nailed on quality.
Posted: Tue Mar 17, 2009 11:05 am Post Subject:
I would try and use common sense on some of them and not send the letter, and would always get nailed on quality.
Surely you've learned by now Das that common sense and claims handling have nothing to do with each other! :wink: :roll:RM, most likely this subro company has filed a lein with the at fault carrier.. If so they (the carrier) will pay them directly out of your settlement first....
Sounds like all is on track with you...keep us in the loop...sorry I don't watch dvd, my husband does...you need to get netfix WAY cheaper than pay per view :wink:
Posted: Fri Apr 17, 2009 03:20 pm Post Subject:
Hi everyone, I'm back! I did file a claim with my own auto insurer, and quickly received a check for the policy limit of $5,0000.00 for med pay benefits. I paid off the outstanding bills that hadn't been paid under my health insurance, and thought I was in the clear. I got a letter today, roughly 3 weeks after receiving the check, stating that my insurance carrier has claimed a lien against my settlement for the $5000.00. With this being the case, do I now increase my demand by $5000.00 at settlement time? Or is there a way to avoid having to reimburse my own carrier since I was legally entitled to claim my med pay benefits on the policy? I was under the impression that UIM and med pay were not subject to being rated up or subrogation. Any ideas?
Posted: Fri Apr 17, 2009 11:00 pm Post Subject:
Are you saying you got a subro demand/lein notice from your auto carrier or your health carrier ? I'm assuming your auto carrier...Different states allow different things...find out first (to be sure) if medpay is subrogatible in your state, (either your policy or your states dept of ins web site should be able to give you the answer)...There is a difference regarding UIM, because your UIM carrier MUST approve your settlement with the third party carrier FIRST...and they (3rd party) won't pay unless they can get a release for THEIR insured..(i know makes my head ache some times too)..
do I now increase my demand by $5000.00 at settlement time?
CertainlyPosted: Fri Apr 17, 2009 11:22 pm Post Subject:
yes it is the med pay in question. I have not yet filed a UIM claim. still in therapy :(
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