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 Posted: Mon Apr 13, 2009 10:44 pm Post subject: Can an adjuster refuse to pay all of my med. bills? |
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I was a passenger in a car that was backed in to. I received a whiplash/soft tissue type injury. It was unclear to my doctor as to the seriousness of my injuries because of the pain I was in. The accident was in September of '08. Over the course of that time, she has ordered xrays and MRI's of my head, shoulder and neck. She prescribed medical massage therapy 1-2 times a week, along with pain meds, muscle relaxers, a TENS unit.
Because the owner of the car I was in had no insurance I put in a claim with my insurance company to have my Medpay cover some of the medical costs (5k) until I was well and ready settled with the 3rd party ins. company. My medical insurance has covered the remainder of my medical expenses minus my copays and my massage therapy, these have been paid for out of my own pocket.
I am 45 years old. I had a similar injury in a previous accident 3 years prior, but I had completely healed from that accident. I live in CO. I have an insurance adjuster that has told me that it is not 'reasonable and customary' for me to still be receiving treatment, that I should be healed, and I need to settle my claim with them or they most likely will not pay for all of my medical costs, which are in excess of 12k. I have told her every time I talk to her that I will not settle until my doctor releases me. Can they refuse to pay all of my medical bills? I am out of pocket over 2k and I don't want to be stuck with all of these expenses. I have followed my doctors orders, and I have not received any treatment that she did not prescribe.
Also, can you tell me what you think would be a resonable amount for me to settle with them? It's been 7 months and I am still being treated. This has really effected my life in a negative way. I don't like being bullied, this alone has caused me a great deal of stress. I appreciate your time. Let me know if you need any additional info. |
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birdhouselady
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| Posted: Tue Apr 14, 2009 12:56 am Post subject: |
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| Your medpay carrier is responsible for reasonable care. In this case it sounds like the adjuster is stating that some of the treatment is not going to correct or help you much... that is, it's only 'feel good' treatment. Usually this would be things like manipulations that are done 3 or 4 months or longer after the accident. However, this is a gray area as to if it's 'reasonable'. |
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tcope
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| Posted: Tue Apr 14, 2009 10:40 am Post subject: |
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Okay, couple of confusions….if I may put them
First of, the OP has stated that her medical bills were taken care of by of her Medpay and health insurance carriers. Then whose adjuster is she dealing with now?
I am again confused since the OP has mentioned that the owner has no insurance. Then gain she has said until I’m ready to settle with the third party.
| Quote: | | Because the owner of the car I was in had no insurance I put in a claim with my insurance company to have my Medpay cover some of the medical costs (5k) until I was well and ready settled with the 3rd party ins. company. My medical insurance has covered the remainder of my medical expenses minus my copays and my massage therapy, these have been paid for out of my own pocket. |
Am I not getting the entire picture? Am I missing out something? Tcope, please help me to understand the scenario.
Thanks,
Rupert |
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RupertWBradson
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| Posted: Tue Apr 14, 2009 12:00 pm Post subject: |
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I'm with Rupert first we need to understand WHICH adjuster we are talking about here your's (medpay thru your carrier) or the Claimant Carrier (bodily injury thru vehicle that backed into the one you were in).? 
Can they refuse to pay all of my medical bills? I am out of pocket over 2k and I don't want to be stuck with all of these expenses. I have followed my doctors orders, and I have not received any treatment that she did not prescribe.
| Quote: | | Also, can you tell me what you think would be a resonable amount for me to settle with them? It's been 7 months and I am still being treated. |
Seven months does sound like a long time for a simple soft tissue injury....sorry... | Quote: | | This has really effected my life in a negative way |
I'm not unsympathic, all auto accidents affect all involved negativiely.... | Quote: | | I don't like being bullied, this alone has caused me a great deal of stress. |
Again, we need some clarity on who it is you think is bullying you....has your company paid your full medpay limit?
Your claim is further complicated (and frankly 'worth' alot less) since you have had a previous injury nearly identical...how long did you treat that time? Also please provide a little more info re: the accident facts...were you setting still when the other vehicle backed into the one you were in? What type of vehicles were each and how much (if any) damage was done to each vehicle?
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Lori
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| Posted: Tue Apr 14, 2009 2:13 pm Post subject: |
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| I understood it to mean that the owner of the vehicle the OP was in did not have insurance. I'm guessing that normally the passenger gets auto MP from the vehicle he/she is in. So in this case the OP needed to go under his/her own policy for auto MP. |
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tcope
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| Posted: Tue Apr 14, 2009 6:49 pm Post subject: |
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Sorry for the confusion. Let me se if I can clear things up. The medpay claim is with my insurance company. They have paid out the limit of 5k.
The adjuster I am dealing with is the insured who hit us (bodily injury).
We were sitting is line at a gas station, I was the passenger, in an 89 Honda Accord Coupe, the guy who hit us was about 6 feet in front of us. He put his GMC Yukon in reverse and rammed in to us knocking us back several feet.
I don't understand why it is worth less because of my previous injury? I had completely healed from my other injury. I was treated for 4 months.
The problem is, I was re-injured in the same exact area. I know that 7 months seems like a long time, but I really don't have control over how long it takes my body to heal. Last month my doctor gave me trigger point injectings to help relax the muscles. She would not do this if I was healed. By the way, she is my primary care doc and she also treated me for my previous injury. Maybe I over simplified my injury. I am also dealing with some nerve issues in my right arm, tingling in my hand, and pain in my shoulder. If I was healed, I would like nothing better than to be done with this whole thing.
I am not ready to settle my claim. I have told this adjuster repeatedly that I will not settle until I am healed and released by my doctor. I just want to know if she can follow through with her threats to not pay all of my medical bills? I appreciate your time. Thank you.
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banged up in CO
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| Posted: Tue Apr 14, 2009 7:47 pm Post subject: |
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| Quote: | | I don't understand why it is worth less because of my previous injury? I had completely healed from my other injury. I was treated for 4 months. |
I don't know that anyone ever completly heals from an injury. Of course every situation is different. The argument is that the current injury is worse because of the prior injury. | Quote: | | I know that 7 months seems like a long time, but I really don't have control over how long it takes my body to heal. |
Understood. What is being said is that chiropractic (or massage therapy) care can only do so much for a soft tissue injury. After a certain amount of treatments its not lending to the healing process it's just making the person feel better temporarily. Kind of like a nice hot bath. As such, it's no longer being used to "treat" the injury. at that point the tissue will heal itself just as well. | Quote: | | I just want to know if she can follow through with her threats to not pay all of my medical bills? |
The adjuster can and even perhaps do that... but the final word is always a judge or jury. The adjuster is letting you know that she/he may raise that argument when it comes time to settle. They may or may not consider those medical bills... that is all part of the settlement process. |
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tcope
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| Posted: Tue Apr 14, 2009 8:50 pm Post subject: |
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My treatments are nothing like a 'nice hot bath', nor do they 'feel good', they are intense deep tissue massage, along with nerve manipulation, and it hurts like heck.
Tcope, are you a doctor? According to my doctor I DID completely heal from my prior injury. So, if I won't completely heal from this injury why would my doctor continue to prescribe treatment? Why wouldn't she just tell me this is as good as it's going to get and release me? I am following my doctor's orders in hopes of getting well.
If I understand you correctly tcope, the adjuster can refuse to pay for all of my medical expenses and if I have a problem with that I will have to hire an attorney and go to court? So either way you look at it I get screwed by the insurance company or I get screwed 33% out of my settlement by an attorney. Do I have any other choices? Neither of these options are appealing to me
I thought the insurance companies have to answer to the DOI. Is this something that they could help me with if the insurance company decides they are not going to pay for all of my medical expenses?
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| Posted: Wed Apr 15, 2009 9:02 am Post subject: |
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Okay so someone backed into you vehicle. From your first post I got the idea that your driver backed into another car.
Previous injuries and that too almost in the same area can make a claim complicated. The adjusters would try to cut a check of less value because of these old injuries.
Thanks,
Rupert |
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RupertWBradson
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| Posted: Wed Apr 15, 2009 2:17 pm Post subject: |
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| Quote: | | Okay so someone backed into you vehicle. From your first post I got the idea that your driver backed into another car. |
There wasn't anyone behind our car. We did not hit anyone. We were backed in to by another vehicle.
You all seem to be saying the same thing. My previous injury gives the adjuster an excuse to pay out less on my claim. No one has answered the question why? My doctor told me that this injury has nothing to do with the previous injury, and that I was healed from the other injury. So, how can the adjuster justify paying out less?
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banged up in CO
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| Posted: Thu Apr 16, 2009 12:05 am Post subject: |
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I want to thank you all for your response. I know that I may have seemed defensive, but the truth is I appreciate you making me defend myself. This is helping to prepare me for when I have to settle my claim.
I have another question. In my research I came across something called "The Skin-Skulled" rule, or "Eggshell rule". Wouldn't this apply to my situation if I in fact had NOT healed from my previous injury?
An additional exposure in tort liability towards persons who are particularly vulnerable or more fragile than the norm, who may have inherent weaknesses or a pre-existing vulnerability or condition; the tort-feasor takes his victim as he finds them; he compensates for all damages he caused, even if damages are elevated compared to a norm because the plaintiff was thin skulled.
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banged up in CO
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| Posted: Thu Apr 16, 2009 11:01 am Post subject: |
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| Quote: | | You all seem to be saying the same thing. My previous injury gives the adjuster an excuse to pay out less on my claim. No one has answered the question why? My doctor told me that this injury has nothing to do with the previous injury, and that I was healed from the other injury. So, how can the adjuster justify paying out less? |
Aggravating a pre-exsisting condition is always worth less than 'causing' the initial injury..which only makes sense...now on the other hand if you can convince the adjuster that this injury was healed 100%...different story, but frankly doubt there has been enough time elapse for that...also in your demand to that settlement how long did you claim you would suffer from that injury?
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Lori
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| Posted: Thu Apr 16, 2009 11:28 am Post subject: |
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Well, I guess the eggshell rule applies to medical negligence cases. I’m not sure if the same applies even to the MV accidents.
Now, the ball had rolled to your court. You are required to prove that you had healed from your initial injuries completely before the accident. Now, if you can proof that the accident has only worsen your condition, you are entitled to receive compensation for that.
Do you have a document which would suggest that you had recovered from your initial injuries before the incident? |
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simon
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| Posted: Thu Apr 16, 2009 2:36 pm Post subject: |
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| Quote: | | Do you have a document which would suggest that you had recovered from your initial injuries before the incident? |
I do not have a document, but I am sure my doctor would give me a document stating that I had recovered from my previous injury. I asked her if I was injured so easily because of my previous injury and she said "no, this injury has nothing to do with your previous injury, you were healed from that injury. This injury is from this accident". I'm sure she would put it in writing for me.
| Quote: | | Aggravating a pre-exsisting condition is always worth less than 'causing' the initial injury..which only makes sense...now on the other hand if you can convince the adjuster that this injury was healed 100%...different story, but frankly doubt there has been enough time elapse for that...also in your demand to that settlement how long did you claim you would suffer from that injury? |
Lori, what would the different story be? I beleive my doctor's diagnosis would have bearing on the out come. There was no demand for settlement with my other accident. I was at fault.
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banged up in CO
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| Posted: Mon Nov 01, 2010 9:52 pm Post subject: |
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I just have to say that I'm an attorney, and the eggshell plaintiff rule would definitely apply to your case. PP is wrong that you would have to prove you were previously injured, it didn't cause it, etc. All you have to do, IMO, is show that you were not receiving treatment for several years, and this required you to receive treatment.
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