Workers comp. - can insurance carrier send applicant accepted claim letter and years later not accept claim?

Asked about 2 years ago - Glendora, CA

Insurance carrier sent me accepted claim letter and now years later at settlement has not accepted claim? However, insurance carrier is paying all medical care I received for injury.

Attorney answers (3)

  1. Nancy J Wallace

    Contributor Level 14

    1

    Best Answer
    chosen by asker

    Answered . Apparently so! I took a similar incident to Trial, the judge found the carrier may accept and then -- on the 90th day -- the attorney can deny the previously accepted claim, so long as it was within the 90 days. AFTER the 90th day from the employer receiving notice, the denial is supposed to be based on new evidence, evidence that could not and was not found within the 90-day investigation following your giving notice to the employer of a work injury.

    YEARS LATER the carrier would have to show that the denial was based on evidence not available until just recently. I do recall a case where the County couldn't get video of the deputy riding horses until 2 years into the claim and denied the claim years into the process and the late denial was upheld as valid...the evidence of the deputy's recovery was concealed until the date they obtain the roping video.

    I suspect that the entire claim is not being listed as denied, just certain body parts. In the settlement agreement the adjuster may note that responsibility for just one body part was accepted but responsibility for the other body parts noted in the medical reports was denied.

    For instance, the adjuster won't agree in the settlement that there is a psychiatric and a shoulder injury when all she accepted liability for was just the neck. This tactic makes the Lien Claimants either prove the psychiatric and shoulder injuries or seriously reduce their bills for studies and treatment on those denied body parts.

    THE GOOD NEWS: I'd be HAPPY if the entire claim is listed as being denied and refuted. If you get in a slip-and-fall or auto accident later and those body parts are re-injured, you can tell an adjuster "the comp claim was denied; i just settled"... and if they are lazy and don't investigate, those medical records stay hidden.

  2. Shaun Cunningham

    Contributor Level 9

    Answered . There is a difference between accepted injuries and accepted body parts. The insurance carrier may accept part of your injury, but not all other body parts or other injuries you may have alleged. You see this a lot with psychiatric claims and orthopedic claims related to compensable consequence injuries (ie, my left knee was injured at work, and now, after some time my right knee hurts due to overuse...).

    Also, at time of settlement, the insurance company is thinking about dealing with unpaid medical liens. If they write that something is denied in the settlement documents, and you agree, the lien claimant may have some difficulty collecting on their bills.

    If you are unrepresented, contact an I&A officer if you need further help. If you are represented, you should ask your attorney your specific questions before signing anything.

  3. George Ellis Corson IV

    Contributor Level 20

    Answered . Under some circumstances, they can. Nancy covered it very well.

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