Off Topic Poker Forums

Want to see if we had any legal experts or experience in dealing with this kind of problems. First off ive been a cop for 13 years and purchased a supplemental insurance policy that helps out with bills or pays you when your off work injured because you miss some pay, overtime holiday pay etc. In December I assisted fire department who was being attacked by someone. I had to fight with him and tore my rotator cuff in the fight. It was obvious workmanship comp claim and had to have a couple xrays and finally an MRI to pinpoint problem. Dr sent me through therapy and cortisone shot to no avail. Finally I had surgery on march 29.

On may 16 I went back to dr who said I'm progressing normally but said I am not able to work and sent me back for 6 weeks of therapy. My insurance company pays for recovery time after surger and payed me for 48 days and said update claim after going back to dr.

On june 29 I returned to dr with only about 70% range of motion and lacking strength. He said I'm doing well but said I'm still not able to work. He filled out claim form for insurance saying I'm still "disabled" and not able to work. Today I get a call from adjustor who says they will not pay anymore because according to them, 42 days is average recovery time for most jobs and I'm over that. I say I'm police which is physical job much of time. I also say if that's the case why is this the first time hearing about it and why if that's the case did they pay me for 48 days and tell me to submit again when I go back.

Now since talking with adjustor I read policy which states that they pay recovery time after surgery in which I'm deemed disabled up to six months period. No mention in the policy/contract about average recovery times anything. I asked three times to talk to supervisor and denied. I am calling back on Monday for a good day long session of talking to adjustor and everyone else at company.

Any advice in this matter will be appreciated. We are talking about a pretty significant stiff of about $4500.

You in the Union? I would be contacting your Union Rep asap. If you were injured on the job, fighting with a suspect the workers comp should be enhanced.
I have been working Law Enforcement 14 years. Some supplemental policies only kick in after you have burned your sick leave. I am not an insurance/legal expert tho. I have been injured on the job but never more than 3 days and workers comp has always covered it.

Thanks for advice. They are not disputing it being workmanship comp. We also don't have to burn any sick days either. I think they are just giving me runaround until I give up. To me the policy is a contract and says they pay up to 6 months for recovery time and dr has not let me return to work and filled out paper saying I'm currently disabled. They are basically saying dr is liar. She said they need to send the dr a form to fill out and then they would consider paying me. I gave her the fax number and she said the forms are in Pennsylvania and would have to wait for them to mail them. It's 2012 and you can't pull them up off computer, BS. I said I would call that office and ask them to fax it to her and she said they can't do that. It's almost laughable.

policy language and insurance law is different in every state but most states have some kind of department of insurance where you can call to lodge formal complaint - this might give you some kind of leverage depending on your state and the company you are dealing with

if you have a relationship with the agent who sold you the policy then i would call them

even if the wind up sending you a denial letter you will likely be able to take claim to some form of arbitration

can't hurt to ask for help form union rep - in some states the unions "endorse" certain insurance companies to write this policies for their member so there is an outside chance there can be some connection

GL

another thought - even if the guy on the other end of the phone is a dope - he is just some dude trying to make a living pushing papers around and doing what he is told

I say this because being nice, making friends, and ask for his help might be your best strategy

Keep calling, keep fighting. They'll end up paying if you don't give up. Log all calls, get names, log them, log what they say. Union rep is best bet. Send certified letters, cc to Union and Dept of Insurance in your State. Keep the letters simple and factual: you were disabled on the job defending a firefighter, you have attended all recommended physical therapy session and doctor's visits, doctor has examined you and determined that your disability continues, insurance company is inappropriately denying coverage, insurance rep said it was because average time of injury is 42 days after this, "average" means half of people take longer to recover [that's actually median but they won't know], denial is inappropriate and not based on policy coverage, etc. You'll win, you just have to keep fighting. Phone calls alone leave no trail, so step up with letters naming names of people you talked to with dates and times. Call daily. Loo at it as being paid $300/hr to collect your money.

Keep calling, keep fighting. They'll end up paying if you don't give up. Log all calls, get names, log them, log what they say. Union rep is best bet. Send certified letters, cc to Union and Dept of Insurance in your State. Keep the letters simple and factual: you were disabled on the job defending a firefighter, you have attended all recommended physical therapy session and doctor's visits, doctor has examined you and determined that your disability continues, insurance company is inappropriately denying coverage, insurance rep said it was because average time of injury is 42 days after this, "average" means half of people take longer to recover [that's actually median but they won't know], denial is inappropriate and not based on policy coverage, etc. You'll win, you just have to keep fighting. Phone calls alone leave no trail, so step up with letters naming names of people you talked to with dates and times. Call daily. Loo at it as being paid $300/hr to collect your money.

This IMO.

Oh, and feel free to mention to the company rep that if they continue their actions you will be speaking with the State Insurance Department, and your lawyer.

Several phone calls later and victory. Had all my ducks in a row and just hammered them with my policy. Kept asking them what section in my policy says they can deny my claim after a dr certified me as disabled. They said they are using mda guidelines that says average is 42 days. I then say ok wheres that in my policy. They then backpedal and say they aren't denying, just need more clarification from dr. I said that they called and said they were denying claim and it wasn't until several minutes of arguing that they said well they might pay but need more doctors forms. Several hours later a supervisor called and said the checks been sent.

report them to your states insurance commissioner and the better business bureau for giving you such a run around. You wasted a whole lot of time forcing them to play by the contract they signed, i would go for some blood with them tbh