At Fault Insurance Carrier response to demand letter

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PostPosted: Wed Jul 28, 2010 10:41 am   Post subject: At Fault Insurance Carrier response to demand letter  

My lawyer sent at fault insurance carrier a demand letter and their response was a request for medical records five years prior to my accident. (10/5/09) My medical bills exceed $26k and my property damage was $24k (they already paid).

We do not know their insurance limits but I am hoping they are at least $50k for bodily injury and not $25.



I am a diabetic with diabetic neuropathy and on long term disability from my employer due to the neuropathy therefore loss of wages were not included in the demand letter.



I have had notprior injuries and my current disabilty claim is all related to the neuropathy. (loss of sensation in my feet)



My injuries from the accident were a fracture to my arm and right wrist, bruised sternum and soft tissue issues in my neck and right shoulder.



What are they looking for?



Is this a good sign that the at fault policy limits are more than $25k? If they were not wouldnt a adjuster just settle for the $25 and be done with this claim?


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PostPosted: Wed Jul 28, 2010 11:30 am   Post subject:   

Quote:
What are they looking for?




They are (1) looking for any evidence that some of the injuries you have reported are preexisting conditions that might or might not have been made worse by the accident, or (2) any way to stall when it comes to paying the claim.



Quote:
Is this a good sign that the at fault policy limits are more than $25k? If they were not wouldnt a adjuster just settle for the $25 and be done with this claim?




I'm sure one or two of the adjusters will weigh in on this, but I don't think you can infer anything specific about coverage amounts from the delay. To an insurance company, a $25,000 claim is not significantly different than a $50,000 claim. But they don't want to pay for something that's not the responsibility of their insured either. Once the money has been paid out, it's near impossible to recover it after an error/crime is discovered.



However, it is ordinarily a requirement of most states' insurance laws that once liability for a claim has been determined, the claim must be paid promptly, usually within 45 days. So an unreasonable delay in paying a claim is a problem between the insurer and the regulator.



Although you are represented by an attorney, it would not hurt to file a complaint with your state's Dept of Insurance over the untimely resolution to your claim. Because they are prevented from intervening once you have an attorney representing your position, that does not prevent them from looking into the insurer's general business practices and claims practices. What they don't know, they cannot investigate. So file the complaint.


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PostPosted: Wed Jul 28, 2010 2:10 pm   Post subject:   

Thanks Max my lawyer sent the demand letter on 7/16/10 and received a response back from the at fault adjuster on 7/21/10.

Another question

Although my accident happened 10/05/09, the fractured was not detected until a MRI was done 1/2/10. Xrays did not show the fracture. I was referred to physical therapy before the fracture was detected by an ortho doctor and then after constant complaints by me he ordered an MRI.

I was put in a cast for 8 weeks then sent to physical therapy again.

Will the insurance adjuster try and use this delay and put responsibility on the doctor therefore lessening the amount of the claim. The doctor ordered xrays everytime I was in his office I guess to keep cost down (since my health insurance was now paying for the medical bills) maybe he did not order the MRI right away I am just guessing. Would this weigh heavily on your mind if you were the adjuster?

Thanks


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PostPosted: Wed Jul 28, 2010 9:29 pm   Post subject:   

Quote:
my lawyer sent the demand letter on 7/16/10 and received a response back from the at fault adjuster on 7/21/10.




And was there anything of substance in that communication?



Quote:
Although my accident happened 10/05/09, the fractured was not detected until a MRI was done 1/2/10. Xrays did not show the fracture.




This is not uncommon. Does your orthopedist believe the fracture was caused by the accident? Or could it have resulted from some other cause?



Quote:
Will the insurance adjuster try and use this delay and put responsibility on the doctor therefore lessening the amount of the claim.




It could be the basis for their need to review medical records, looking for preexisting or non-collision-related injuries. But if related to your collision injuries, it will not diminish your claim.



Quote:
my health insurance was now paying for the medical bills




Be aware that if your injury is found to be collision-related, your medical insurance company has the right to, and certainly will, subrogate their loss. If you collect damages for your injuries, they are entitled to 100% of the value of the services provided on your behalf at their expense. This is something frequently overlooked by attorneys when negotiating a settlement.



Think of it this way: If you crash your car, causing your own injuries, your medical insurance will cover, no questions asked. You cannot sue yourself via your auto policy for you damages. But if someone else crashes into you, and it is determined to be their fault, they are liable for your injuries. Your medical insurance is not intended to cover such "third-party damages" to you.



So when considering the value of a settlement from the at fault party (or their insurer), any of your medical or other bills paid by your own insurance (medical or auto) need to be accounted for separately, and those bills need to be paid by the at fault party's insurance company over and above the money you and your attorney will share.



If your attorney fails to do this, after taking his 1/3 off the top, you might discover that the remainder is not sufficient to cover the balance owed to your medical insurance company or your auto insurance company, and you could wind up with nothing for your trouble -- you could potentially OWE them any unpaid difference.



A good attorney will not let this happen. Unfortunately, there must not be that many good attorneys, because this happens all too often.


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PostPosted: Thu Jul 29, 2010 6:29 am   Post subject:   

Quote:
Although my accident happened 10/05/09, the fractured was not detected until a MRI was done 1/2/10. Xrays did not show the fracture.





This is not uncommon. Does your orthopedist believe the fracture was caused by the accident? Or could it have resulted from some other cause?





Medical records are secured all of the time. Attorneys always promise they will send them and adjusts wait and wait and wait. But I am guessing a broken arm/wrist that 3 months after the accident popped up, may have triggered the request. They want to see the medical notes of the doctor that discovered the break and see his thoughts on what happened. Although not all injuries show up directly after the accident, three months with no documentation of the injury is difficult to explain. The records may or should show what took place during your visits.





Quote:
However, it is ordinarily a requirement of most states' insurance laws that once liability for a claim has been determined, the claim must be paid promptly, usually within 45 days.




Although this is true, (days may be different depending on state) as long as the carrier explains what additional is needed (medical records) they can extend that time period.


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PostPosted: Thu Jul 29, 2010 1:09 pm   Post subject:   

Thank you both for the information I will be sure to follow up with my attorney. I lived in Kentucky



Max - his response back to at adjuster was that it was irrelevent due to my disability is from diabetes and the condition I have has not affected my right arm or shoulder however if needed they already have a signed release form from me and if needed I would consent to releasing the medical records from the doctors treating me for my diabetes.

And yes the ortho surgeon said fractures sometimes to do show up on xrays right away. The day after the accident I went to my primary care doctor and he referred me to an ortho surgeon. We took pictures of all my injuries and my wrist was swollen really bad and had cuts and bruises. Each visit with the ortho doctor xrays was taken and the doctors notes indicate I complained of pain each time I was in his office.



Dasfunk

Between the date of the accident and when the MRI was finally done the records from my ortho surgeon are well documented I was seen every two weeks and also had painful physical therapy (3x a week) from the same office. The physical therapist and the ortho surgeon work out of the same office so notes from each were taken on each visit so there was not gap between the accident and when the fracture was detected


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PostPosted: Thu Jul 29, 2010 4:25 pm   Post subject:   

Quote:
as long as the carrier explains what additional is needed (medical records) they can extend that time period.





Regulations vary some from state to state, but they all should be fairly similar. As an example California law requires communication from the Insurer to the claimant every 30 days if a resolution has not occurred. This claim is now 9 months old. Way too long to resolve.



Definitely warrants a complaint to the State Dept of Insurance, even though an attorney is on the case. Insurers have paid big fines for such "market conduct" violations as failure to communicate.


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PostPosted: Thu Jul 29, 2010 7:06 pm   Post subject:   

Quote:
Regulations vary some from state to state, but they all should be fairly similar. As an example California law requires communication from the Insurer to the claimant every 30 days if a resolution has not occurred. This claim is now 9 months old. Way too long to resolve.





I think it is 30 days in Ohio as well. When an attorney is involved, I would just shoot a letter to them asking for their demand package and/or their clients progress. This would cover my 30 day requirement.



9 months with an attorney involved is not long. Most accidents that I handled that had an attorney took 6 months mininum. I'd just sit on my hands shoot out my 30 day letter and wait. (I wasn't going to just spit out dollar amounts until I knew their demand.) 6 months later I would receive a demand package with no medical records just EOBs/bills and their reach for the sky demand. I would then ask for the medical records and it would take another 30 to 90 days for them to respond. (Mind you, my first letter to acknowledge that they were reping the claimant would ask for everything I needed. But why would they read it, no one reads anything an adjuster writes. (carriers included)


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PostPosted: Fri Jul 30, 2010 2:15 am   Post subject:   

My attorney wanted to waited until I finished all of my treatment ie., physical therapy and received a release from my doctors before he would start the process of the demand letter. I completed all my medical care and was released by all of my doctors in May. My lawyer said he would then send a request for medical records to all of my doctors and xrays then prepare a demand letter which he did a few weeks ago

I just hope this doesnt drag out for ever they are requesting to get medical records going back 5 years for all of the doctors that are treating me for my disability.

It is the waiting game now I guess


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PostPosted: Fri Jul 30, 2010 4:30 am   Post subject:   

Quote:
Mind you, my first letter to acknowledge that they were reping the claimant would ask for everything I needed. But why would they read it, no one reads anything an adjuster writes.




Seems that dasfuk's omniscience was showing here. A+++



Quote:
My attorney wanted to waited until I finished all of my treatment




Well, if we had known that up front, our responses would have been a bit different. You can chalk up all the delay to your attorney. Well, at least 90% of it, if not 100%.



You should have been supplying doctors' records all along. Whatever is now causing the delay at the insurer would have been water under the bridge months ago. Knowing that your treatments were not complete would alert the insurer to not expect to settle the claim yet, but their determination of your claim status would probably have been long settled, awaiting only your physician's final release from treatment.



Whatever they expected to find by going back five years would easily have been found long before now, and if it was a matter of concern, you could have dealt with it, too. Leave it to a lawyer to make things more complicated that it needs to be. How/why did you even get connected with a lawyer in the first place?



You should sue your lawyer for the aggravation he has caused you. Or at least demand a reduction in his fee for all your trouble at his expense.


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PostPosted: Fri Jul 30, 2010 6:52 am   Post subject:   

Quote:
You should sue your lawyer for the aggravation he has caused you. Or at least demand a reduction in his fee for all your trouble at his expense.





Most people don't get it. Attorneys sign people up. The more people they sign up the more money they make. They tell you to wait till you are done treating and then get back with them. I'm sure they set a diary sort of like an adjuster and get in touch with their clients from time to time and might shoot a letter of their own to adjusters.....but that seems about it from claimants I have spoken to. Most of the demand packages I got were junk. It looks like they jammed some sheets of paper together and stuck it in the mailbox. Mind you the part of the package that had the demand was a clear and neat as could be. They don't put real time into your "case". They are hoping to settle as quick as possible. Time is money and the more cases they get closed the more they make.


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PostPosted: Fri Jul 30, 2010 1:01 pm   Post subject:   

wow I didnt know to send adjuster weekly updates on my condition and my attorney didnt ask either he said "just check in every few weeks or so" then once I finish treatment he would send a demand letter to the adjuster. Oh well too late now darn. I am going to the attorney office today anyways to sign medical releases again and give name of the doctors treating me for my diabetic complications ie., neuropathy and kidney disease preventing me from working at this time.


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PostPosted: Fri Jul 30, 2010 1:56 pm   Post subject:   

I don't know about "weekly" updates, monthly would probably have been fine (up to the insurance company to decide).



The point is, the insurance company is maintaining a file that essentially nothing has been done with, thanks to your attorney, and now they're going to receive everything in a "lump" (assuming your doctors all cooperate and send in copies of your records in a timely fashion -- some, however, may expect the insurance company to send a person to their office to gather the records that are needed, in which case nothing will happen until someone visits the doctor's office -- if the insurance company wants it, the doctor is not obligated to spend money to provide it), and will have to start combing through the material page-by-page looking for whatever it is they think they want or need to see.



How long will that take, considering there could be five years of treatment records and thousands of pages total? Two months, four months, six months? Longer? Your attorney did your matter no small disservice by choosing to "wait" until your treatment was finished. What if that was going to be a never-ending thing?



And each of these "visits" to your attorney to review your case, sign release forms, discuss response letters, etc . . . they are not free. You could just as easily sign those release forms at your kitchen table and mail them back. $0.44 vs $200+. Who's "winning" here?



Truly, when it comes to insurance matters like this, the only time an attorney may truly be necessary is AFTER the insurance company denies your claim, or you believe is dragging its feet unnecessarily. People often rush to hire an attorney because they have a very misguided view of insurance company claims departments, mostly due to anecdotal information, which is usually wrong (just read some of the posts on this website), that insurance companies "never" pay claims.



Just isn't true. Companies pay billions of dollars of claims every year. They just don't want to pay claims they have no responsibility to pay -- and sometimes that can take a few weeks or longer to determine. And despite their best efforts, insurance companies get hit with hundreds of millions of dollars in fraudulent claims each year, too, much of which they have paid before the fraud is discovered.



Still, long before a person retains an attorney, the free services of the state's Dept. of Insurance can sometimes get the insurance company to change its attitude or move more quickly, if an insured or claimant feels they are being mistreated by the company in some way. (When you look at the statistics, the number of "justified" complaints vs. total complaints against insurers is relatively low, so what does that reveal?)



Generally, you have two years (or more, I've learned, depending on the state) from the date of loss to file a legal action (i.e., civil suit) against an at fault party or an insurance company over a claim, so rushing off to find an attorney is not an immediate need. In your case, it would be a suit against the at fault party, not the insurance company, since it is a third-party matter.



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PostPosted: Fri Jul 30, 2010 2:17 pm   Post subject:   

Quote:
Most people don't get it. Attorneys sign people up. The more people they sign up the more money they make




Exactly! When you see all those ads on TV for personal injury attorneys, what they don't tell you is, "How many times have we actually taken a case to trial? Uh . . . none."



Pay close attention to the language of the advertisement and you will hear, "If your case doesn't settle, you won't owe us anything." Funny, but your idea of the word "settle" probably means going to trial, their idea is, we get an offer from the insurance company.



Here's the real issue: if the insurance company makes an offer, but you don't really like it, you can continue to negotiate for a better offer. Happens all the time. But when you have a lawyer involved, they don't always have the negotiation skills their ads lead you to believe they do.



If they tell you, "Well, I think this is the best we'll be able to do," you might reply, "Then I think we should go to court and get more."



Then you'll hear this, "Well, if we go to trial and lose, it's going to cost you thousands of dollars for my time, the cost of investigators, all of the court fees and costs, like the jury and court reporter and all, and you may even have to pay the other party's attorney's fees and all their expenses."



"But you told me that if I lose, I won't have to pay you anything."



"No, what I said was if your case doesn't settle, you won't owe me any money. That means if the insurance company doesn't pay your claim because they don't have to, then I don't charge you for my time. But, see, they offered $5,000. And I think that's the best we can expect. So if you take that offer, I get $1500 and you get $3500. I've never gone to trial before, and I could lose. If I do, you'll have to pay me for all my time, all the costs, everything."



So you take your $3500 and go away mad at the insurance company and mad at the attorney, when you should only have been mad at the attorney. If the insurer will only pay $5000, they would have paid the $5000 to you . . . without the attorney.



Live and learn.



Tom Hanks said it best in Philadelphia to Denzel Washington: "What do you call 100 lawyers at the bottom of the ocean? A good start."


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PostPosted: Fri Jul 30, 2010 11:17 pm   Post subject:   

wow wishing I tried it solo now..darn..Sad


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