Dangerous Trends: Insurance Companies Denying Workers Compensation Claims

This article covers several worrying trends in the relationship between insurance companies’ behavior and workers’ compensation claims, including:

• The frequency with which insurance companies are denying workers’ compensation claims,
• The tactics they use to deny or complicate workers’ compensation claims, and
• The reasons behind this shift in insurance company behavior and their impact.

Are Insurance Companies Accepting Or Denying Workers’ Compensation Claims More Frequently?

The last few years have witnessed an acceleration of a decades-long trend of insurance companies denying more and more workers’ compensation claims. In North Carolina, it used to be that insurance companies faced penalties and consequences if they denied an ‘obvious’ claim.

Now, unfortunately, political shifts have made it easier and easier for insurance companies to deny claims they know they should be paying for. This puts an inordinate amount of pressure on injured workers to go away, to use their health insurance to pay for medical treatments, or to go back to work before they are ready and healthy enough to do so safely.

This, in turn, is causing more and more people with compensable claims that should be paid to not pursue those claims. This could be because they do not have the means to fight a denial, do not have health insurance, or cannot afford long spells away from work, even with the strong possibility of them having compensation later on if they win the case.

The fewer people who fight against these insurance companies’ wrongful denials, the more insurance companies can get away with it in North Carolina and throughout the country.

How Do Insurance Companies Fight Medical Recommendations?

Insurance companies are increasingly taking the position that an injured worker needs to prove their case for compensation. They insist that workers explain why, through medical evidence, they deserve payment for medical treatment.

It has become quite common for insurance companies to go through discovery by asking questions in a recorded statement or getting pre existing medical records. They are seeking evidence to make the argument that the medical treatment that is being recommended by the doctors is related to something besides workplace injury, such as prior injuries or accidents.

They will argue that surgery from a childhood sports injury or getting injured around the house years ago is the “true” reason for the necessary medical treatment now. If a body part is now affected by a work injury, insurance companies try to find a way to explain the doctor’s medical recommendations are related to a prior injury to or near that body part.

While insurance companies are less likely to argue over the cost of certain procedures, they are certainly debating their necessity, or their connection to a workplace injury more and more frequently.

Insurance companies avoid denying medical recommendations for reasons of expense or being unnecessary because they will have a tougher time arguing that a doctor’s medical recommendations were unnecessary or unreasonable when they are the ones who chose the doctor in the first place.

So, instead, they argue that the injury or medical treatment required is connected to a different or past injury, rather than a workplace accident.

Why Do Insurance Companies Fight Medical Recommendations?

There are, unfortunately, many reasons why an insurance company might fight against a medical recommendation. At the core, they boil down to not wanting to pay for the expensive medical treatments advised, even when they clearly should be.

If someone is out of work, they are not drawing the same income they had previously. Then a doctor offers a solution to correct the problem, providing treatment that will let the injured worker return to work. By denying the medical recommendation, the injured worker will be frustrated and might consider the possibility of just using their own health insurance instead. It might push them to find other means to get treatment and avoid the red tape that workers’ compensation carriers put up. This means the workers’ compensation insurance company will not have to pay for the treatment.

How Do Insurance Companies Build A Case For Denying Medical Recommendations?

When the insurance companies argue that the medical recommendations are not related to the work injury, but rather are caused by something else, this can be used to put pressure on the injured party and give the company time to build a case against them. The insurance companies will demand some kind of discovery, which could include…

• Reviewing prior medical records,
• Looking into the claimant’s past health history, and
• Investigating previous work injuries or accidents.

This is all so that they can argue that the treatment being requested is related to something else in the past.

This discovery process can be incredibly difficult for the claimant to safely navigate. After an elbow injury, for example, one of the questions an insurance company might ask is “Have you ever had pain in your arm before?” That is an incredibly broad and vague question. Do they mean from the time you were born or were a toddler? When you were little and got hit by a pitch and had to put ice on it for ten minutes and never thought of it again? Does that count?

They are hoping that if they ask this broad question and the injured worker says no, they will find a medical record that proves them wrong. Even something innocuous like a bad reaction to a vaccine shot in their arm in their twenties. Now the insurance company will say you complained of pain 15 years ago and you lied about that to us in your discovery responses, so now we do not trust you.

This allows the insurance company to build a credibility argument against the insured worker before they pay for the medical treatment.

How Can Insurance Companies Get Away With This?

The reason insurance companies pursue such tactics and try to avoid paying at every turn is because they know how hard it is to fight back. Right now, insurance companies have seen that they are protected by the industrial commission and its decisions. They will happily make the injured worker go to court to prove that it is all related and necessary and reasonable.

This can be particularly daunting when the insurance company is trying to protect a big business. The employer in the industrial commission is politically leaning towards the protection of big business in the state. As a result, a lot of people are not inclined to go and fight the insurance company and they are not sure that the industrial commission is going to have their back later.

This means that if you want to fight back against the insurance companies, it might be an uphill battle. It will take time and it might not be cheap. Insurance companies count on this to dissuade workers from fighting back.

The fight is not a hopeless one, though, and attorneys who specialize in dealing with insurance companies’ denials and workers’ compensation will fight so that you get the medical treatment you deserve.

For more information on Insurance Denying North Carolina Workers’ Compensation Cases, a free initial consultation is your next best step. Get the information and legal answers you are seeking by calling (833) 444-4127 today.