An injured workers calls our office. They describe the accident. They tell us the insurance company provided some medical care. The insurance company may have even paid some compensation to them while off work. But, the insurance company suddenly told them it was now disputing the claim. That’s what prompted the call to our office. How can my employer provide some benefits and then turn around to dispute the claim?
It’s a good question. It really does not make sense. It seems wrong. But, Alabama law does allow your employer (or its insurance carrier) to pay some benefits and then later dispute the claim. The Alabama Workers’ Compensation Act (Section 25-5-56) specifically says:
In order to encourage advance payments, it is expressly provided that the payments shall not be construed as an admission of liability but shall be without prejudice.
Since it’s a frequent question, I thought I would discuss the issue a little more. So, I’ll talk about the reasons why this happens.
Why Does Workers’ Compensation Encourage Advance Payments?
The primary purpose of workers’ compensation benefits is to treat and rehabilitate injured Alabama workers so they can return to gainful activity. That’s the main goal of the system. And, it’s the main goal of men and women facing a serious personal injury.
When I talk to people following a work-related accident, their primary concern is almost always getting better and getting back to work. I totally understand.
Our system was intended to help people get needed treatment and get basic benefits to survive while healing. Unfortunately, in recent years, many insurance companies have ignored this intent. Instead, too many insurance companies delay treatment, ignore phone calls, throw-up hurdles to benefits, and treat working men and women poorly. I’ve written countless times about bad insurance company tactics that harm workers, their families and our communities. Today, I’ll just talk about the statute that allows advance payments. It’s intended purpose is to help workers get treatment and benefits started without delay.
Why Would The Insurance Company Later Deny The Claim?
So, why would the insurance company provide some benefits but then later try to deny the claim? Numerous possible reasons exist. I’ll briefly discuss a few of them.
- Emergency Care Is Needed. The moments after an accident may present a life or death situation. Time is critical. Emergency care may be required. Maybe the injured worker is carried to a local emergency room. Maybe the injured worker is taken to a local occupational health clinic. The need is too urgent to wait for an adjuster to investigate all the details. Sometimes, the worker receives emergency care and the adjuster later learns reasons that support a denial.
- The Adjuster Takes The Word Of The Initial Doctor. Maybe the initial evaluating doctor says the condition is work-related. Later, a specialist (or other doctor) says it is not. This creates an issue.
- The Insurance Company Hires A Biased Doctor To Deny The Claim. You’ve probably heard the term “hired gun.” Adjusters often try to generate biased medical reports in order to deny, dispute or reduce, claims. Often, this involves a so-called IME (Independent Medical Exam). Insurance companies love to hire biased doctors for what they call an “IME.” Trust me, there’s nothing independent about them. In one recent case of mine, the insurance company hired an “IME” doctor (before the client hired me). That IME doctor did a report claiming the worker’s disability was due to some event 20 years earlier. It was ridiculous. The person worked and lived without problems for 20 years before the recent accident. We were able to defeat this allegation at trial.
- Subsequent Investigation Reveals More Information. After a serious work-related accident, the adjuster may only have basic information. Later, the adjuster learns other issues exist. Maybe it’s issues like horseplay, intoxication, or misconduct. Sometimes, these issues are legitimate. Other times, they are created in bad faith by the employer or insurance carrier to deny a claim.
- The Defense Lawyer Sees An Issue. Sometimes, this is legitimate. Other times, it is not. In Huntsville, we have a defense lawyer who always alleges (in bad faith) some type of ridiculous misconduct to fight valid claims. He’s alleged some truly crazy reasons over the years. This insurance company lawyer routinely alleges things which are clearly false and proven false at trial. I think his actions are unethical and awful. They are absolutely disrespectful to injured workers and our courts. Lawyers like that one give all lawyers a bad name.
- The Insurance Company Wants To Push The Worker Into Settling The Claim. Some adjusters try to push the worker into a low settlement by denying or disputing the claim.
- The Insurance Company Obtains A Positive Drug Test After the Accident. When you are hurt on the job, many employers require a drug test. Sometimes, the local occupational clinic seems more concerned with getting a drug test than with your immediate injury or pain. If this test is positive, the adjuster may use it to deny your claim.
- The Insurance Company Hires A Case Nurse To Manipulate Medical Treatment. After your injury, a case nurse suddenly appears at your medical appointments. She smiles and seems friendly. Too often, these case managers view themselves as tools of the insurance company. Some of them manipulate your care or try to manipulate the doctor into negative opinions.
A work comp claim might later be denied for numerous reasons. Sometimes, the denial reason is valid. Many times, it is not. I’m glad our law allows advance payments so that medical treatment can start. Don’t think these advance payments mean the insurance company has admitted your claim.
If you face any issues with your claim, seek experienced legal advice. Workers compensation benefits are there for you. These benefits can be complicated. Insurance adjusters know the rules. Make sure you seek counsel from someone who does as well.
From its office in Huntsville, the Blackwell Law Firm represents people with serious personal injuries across Alabama. Our lawyers routinely appear in courtrooms statewide.