Insurance Claims Handling

 

Medical Insurance Disputes, Hospital Bill Errors & Medical Bill Errors

Can You Trust Your Auto Insurer – CBSNews.com  More on Allstate.  But, of course, that’s why you need a lawyer!

 

All cases reported here are strictly factual and are not opinion. Documents which contain the facts for all cases reported here are available upon request.

Allstate Before you buy insurance from Allstate, read the transcript on ABC’s show 2020.  ABC’s 2020 stated: “Allstate Insurance has made billions of dollars selling insurance with its famous slogan, “You’re in good hands with Allstate.” But Brian Ross reports on allegations that the insurance giant played hardball with desperate homeowners after a Los Angeles earthquake four years ago, relying on questionable experts and falsified reports and short-changing policy holders, perhaps for as much as millions of dollars.”.

Allstate cancelled the writer’s auto insurance policy (in December 1998) for failure to pay the premium when due.  Although I stated that I did not receive any notice warning me that the policy would be cancelled and offered to sign an affidavit stating so and to pay the premium immediately, Allstate refused to reinstate the policy.  Allstate claimed that they did send a notice and only offered to sell a new policy at a higher premium.

Liberty Mutual has apparently begun scheduling IMEs (Insurance Medical Exams) within just weeks of an automobile accident, so soon after the accident, that diagnostic records are not yet available to be reviewed at the IME. Liberty Mutual has done this recently in several cases the writer has had with Liberty Mutual.  The IMEs were even scheduled before the injured claimant could file an application for No-Fault benefits and before the injured claimant retained an attorney. Without diagnostic records to substantiate the injuries, it is difficult for the IME doctor to justify continuing treatment and treatment could be denied early on.

Liberty Mutual denied orthopedic medical treatment and therapy to a 12 year old who was sitting in the right front passenger seat of his father’s car when his door was struck by a 4 wheel drive vehicle which was speeding at a very high speed in a drag race. The 12 year old was airlifted to the hospital with multiple and severe injuries, including a lacerated liver and back injuries.  Although the accident occurred on 05-06-97, on 08-21-97, Liberty Mutual asserted its right to send the boy to a doctor for an IME (Insurance Medical Exam) whereupon the doctor stated that the injuries had resolved and Liberty Mutual then denied further coverage.  The boy and his parents have stated that the injuries had not resolved at that time and his own doctors said that he needed further therapy.

Atlantic Mutual Insurance Company settled a personal injury claim in Rockland County, NY (not a good county for getting high jury verdicts) where the plaintiff, Mr. V., was struck in the rear and suffered a discectomy at C5-6 (removal of a vertebral disc in the neck).  This is a serious injury and Atlantic Mutual did the right thing by offering $290,000 from their $300,000 policy early in the case before depositions had been conducted. This saved the company legal defense costs to defend an undefendable position; saved their insured from a verdict in excess of the policy; and allowed the injured party to attempt to get his life back in order at an earlier date.  We believe Atlantic Mutual acted as a responsible insurance company and did the right thing!  Plaintiff’s Counsel: PHILIP L. FRANCKEL, ESQ.

Progressive Insurance Company allowed Mr. V., in the above mentioned case, to obtain two years of beneficial medical treatment without being harassed by Insurance Medical Exams and denied further medical payments! Progressive deserves substantial praise for their responsible handling of this No-Fault claim!

State Farm Insurance Company  ($473,000 Verdict reduced by the jury from 1.3 million!, Supreme Court Nassau County May 1999).  State Farm’s insured, while driving a rented Ryder Truck, struck the injured plaintiff in the rear, on 06-29-90, causing a serious and permanent TMJ injury (the TemporoMandibular Joints which allow the jaw to open & close) requiring the plaintiff to undergo bi-lateral surgery (on both sides) of the jaw.  State Farm never made an offer (not even $1.00) to settle a claim against their insured’s, $500,000 policy for 8 years.  Approximately one year before the trial, State Farm offered $200,000.  At the trial, State Farm offered $250,000, then $260,000, then in the middle of trial, the law firm that State Farm hired, replaced their attorney with the senior partner and offered $310,000.  The plaintiff wanted to accept the offer of $310,000, however, at midnight, after a night of many telephone calls, Philip L. Franckel, Esq., had convinced the plaintiff to decline the offer and continue to verdict.  The case went to the jury on 05-17-99, resulting in a verdict of $473,000 on 05-18-99.  It is Mr. Franckel’s policy not to accept even reasonable settlement offers in the middle of trial.  Once trial has started, the amount of resources and money to prosecute the case has mostly been spent and Mr. Franckel believes that his client should tell her story to the jury and receive a verdict, good or bad. Unfortunately, the plaintiff is not entitled to interest on the judgment from the date of the accident, so State Farm was able able to keep the interest earned on the money.

Although the jury announced a verdict in favor of the plaintiff in the amount of $473,000, the jury erred when they announced that they were awarding this amount only “under the condition that the money be paid today and not over the remaining 37 years of the plaintiff’s life”.  The jury had considered an award of approximately $1,300,777 ($250,000 for the past 9 years @ $27,777.77 per year + $27,777.77 per year for the remaining 37 years of life + $23,000 past loss of services), however, they reduced it (like the lottery) to an amount to be paid today (present net value), unaware of the fact that jury awards are paid at the time of verdict and not over the life of a plaintiff.  The judge refused to send the jury back to correct the award.  The defense moved for a new trial (I still do not know why) and PHILIP L. FRANCKEL, ESQ. joined in their application for a new trial.   When arguing the motion for a new trial, the judge granted a new trial and told us to pick a jury today. We advised we were ready, but the defense stated, “Your Honor, We didn’t really want a new trial, maybe we can go out in the hall and settle this.”  The case was settled in the hall.

In this case, State Farm retained doctor #1 to examine the plaintiff and testify at trial.  Doctor #1 stated, in writing, “At the current time there appears to be significant mandibular disability. This disability appears to be severe and distributed on the left and right side.”. At the current time, there is significant loss of function and the functional level is twenty percent.” (loss of function is 80%) “Normal function will never be gained again…”. Treatment has been medically necessary and appropriate “though resolution has not been forthcoming. For this reason, treatment should continue, however the specific directions are somewhat unclear. At the very least pain management techniques must be rendered.”. “Future surgery may be required, along with supportive measures”. “Insurance liability must be kept open to its fullest degree for an undetermined period of time.”.  State Farm was obviously very unhappy with the honesty of doctor #1, so they sent the medical records to doctor #2. Of course, State Farm did not have doctor #1 testify at the trial, and they called to trial only doctor #2 who testified that TMJ is never caused by trauma.

The plaintiff was advised by her dental surgeon to get a bridge for her teeth as this could help to alleviate her pain but the plaintiff could not afford the $18,000 cost of the bridge which was not covered by medical insurance.  State Farm’s attorney argued to the jury that the plaintiff’s failure to get the bridge should be considered as a reason to reduce the verdict.  The attorneys for Ryder Truck which owned the rental truck, and which is financially responsible for any excess judgment over State Farm’s $500,000, sent several “Bad Faith” letters to State Farm alleging that they were acting in bad faith for not paying the policy. You decide.  Has State Farm acted responsibly and protected their insured’s assets from a potential jury verdict in excess of the policy?  Has State Farm acted to help the injured plaintiff in her time of need? Plaintiff’s Counsel: PHILIP L. FRANCKEL, ESQ.;  Plaintiff’s medical expert:  Leonard Hoffman, DDS;  Defendant’s Counsel: SCALZI & NOFI; Defendant’s medical expert: Arthur W. Kupperman, DDS.

Allstate settled (in Dec 1995) and paid $90,000 of a policy with a limit of $100,000 to Mr. Villalobos, a claimant, represented by PHILIP L. FRANCKEL, ESQ., who suffered 50 sutures (stitches) at his right eye.  This case was not in suit and while I wanted the entire policy, I certainly can’t say Allstate was unfair in this case.

The Hanover Insurance Company settled and paid $50,000 to a claimant, represented by PHILIP L. FRANCKEL, ESQ., who’s shoulder belt ruptured a saline breast implant when she was struck in the rear by Hanover’s insured.  The plaintiff had to undergo additional surgery to replace the implant. This amount was paid quickly and prior to a lawsuit being started.  Hanover acted responsibly and fairly with this claim!

The Hanover Insurance Company settled and paid $45,000 to a claimant, represented by PHILIP L. FRANCKEL, ESQ., who slipped on an orange peel in a parking lot which came from an overflowing garbage bin. The problem of overflowing garbage had been previously reported to the condominium association.  The 68 year old claimant had an MRI which indicated a suspicion of a torn rotator cuff tear and had four months of physical therapy.  This amount was paid quickly and prior to a lawsuit being started. Hanover acted responsibly and fairly with this claim!

Eagle Insurance Co.  This is an interesting case.  The client/plaintiff who’s car was struck in the rear by Eagle’s insured, went to one attorney to get reimbursement for her car which was totaled, however, the client also went to another attorney (Philip L. Franckel, Esq., creator of this web site) to recover for her personal injuries.  Neither attorney knew about the other.  The attorney handling the property damage claim brought suit in small claims court (I have no idea why, since the plaintiff was struck in the rear) and settled the claim in court.  That attorney had his client sign a pre-printed form release.  The release was a general release releasing all claims and the attorney failed to write wording on the release to exclude personal injuries. Upon serving a complaint for personal injuries, the defense attorneys hired by Eagle Insurance called saying “we have a problem, your client signed a release for all claims including personal injuries.”.  

The defense attorneys advised Eagle Insurance of the release and Eagle sent a letter withdrawing their previous offer to arbitrate the case and advised that they considered the matter released.  Philip Franckel argued that the amount of the release matched the amount of the property damage; that it was obvious that the intent of the release was to release only liability for property damage; and that there was substantial case law which would support voiding of the release as to personal injuries. Shortly thereafter, Eagle Insurance called to say that after reviewing the case they decided that Philip Franckel was correct. They reversed their position and offered a settlement which was accepted. Eagle Insurance deserves praise for their decision.

There are several morals to this story: 1) Never retain separate attorneys for the property damage claim and the personal injury claim unless both attorneys are aware of and co-operating with each other; 2) When signing a release for property damage, make certain that the release states that it is for property damage only; 3) Never start a lawsuit in small claims court if you anticipate a claim for personal injuries. Trials in small claims court are done without the benefit of depositions and usually without the benefit of testimony by expert witnesses.  Additionally, the rules adhered to in higher courts are substantially relaxed in small claims court.    Consequently, an incorrect decision could be reached in small claims court.  Had this case gone to trial in small claims court and a decision was reached determining that the plaintiff had been at fault or partially at fault it would be binding upon a later personal injury trial due to the doctrines of collateral estoppel and res judicata.

Allstate settled and paid the policy limit of $25,000 to Mr. Sedgh, a plaintiff, represented by PHILIP L. FRANCKEL, ESQ., who suffered a fractured right 5th finger (pinky) without surgery, but which involved the joint.  They strenuously objected, but finally gave in. Not only were they fair, but believe it or not, it was Allstate!

State Farm Insurance Company settled and paid the policy limit of $16,000 to Ms. Fisse, a claimant, represented by PHILIP L. FRANCKEL, ESQ., who suffered a very small scar on the inside of her lip without surgery or sutures.  She bit her lip when she was hit in the rear while stopped at a light.  The case was not in suit and State Farm was very fair. (I have usually found State Farm to be fair with the lesser injuries, but never with serious injuries).

Tri-State Consumer Insurance settled and paid $18,000 to Mr. Fouerti, a claimant, represented by PHILIP L. FRANCKEL, ESQ., who suffered a fractured right 5th finger (pinky) (the claimant was left handed) without surgery and without joint involvement. The case was not in suit and Tri-State was very fair.

Travelers Insurance and CNA Insurance Co settled and paid $300,000 to a plaintiff, represented by PHILIP L. FRANCKEL, ESQ., who suffered a torn Achilles tendon with surgical repair (not disputed as caused by the accident) and a torn meniscus which was disputed as having been caused by the accident because the first complaint of knee pain was four years after the accident; and $130,000 to the other plaintiff, also represented by PHILIP L. FRANCKEL, ESQ., who suffered an injury to the elbow bursa which required an Olecranon bursectomy (surgical removal of the bursa at the elbow) (not disputed as caused by the accident) and a possible scapula fracture (diagnosed by the patient’s orthopedist because of a slight translucency in the X-Ray) which was disputed because the patient’s radiologist’s X-Ray report stated that there was no fracture. Liability was not in dispute, since the Plaintiffs were injured when they fell as a staircase leading from the ground floor to the basement, in a private home, collapsed. Travelers and CNA cooperated and got together to fairly settle this case at a mediation.

Fireman’s Fund settled at mediation and paid $50,000 to a plaintiff, represented by PHILIP L. FRANCKEL, ESQ., who suffered a TMJ injury without surgery.  The TMJ MRIs were normal.  Liability was not disputed. Fireman’s fund was very fair.

State Farm Insurance Company refused to make an offer and this case was arbitrated at National Arbitration & Mediation with a high low parameter of $0 to $100,000 (policy limit).  In this case the plaintiff, who was the driver of his car, hit his knee on the dashboard when he was struck in the rear.  An ambulance arrived and treated his knee with an ice pack and ace bandage.  The plaintiff did not go to the hospital, but drove a few blocks to work and called his sister to pick him up because his knee was swollen and he couldn’t drive.  The plaintiff saw a chiropractor three days later, who referred him to an orthopedic surgeon for treatment of his knee.  A torn meniscus was diagnosed and arthroscopic surgery was performed.  Defendant’s contentions:  the plaintiff did not go to the hospital; the ambulance report could not be found;  the first doctor the plaintiff saw was a chiropractor;  and the orthopedic surgeon indicated on the operative report a post operative diagnosis of “degenerative tear” of the medial meniscus.  The arbitrator awarded $65,000.00.

Colonial Penn The plaintiff was hit in the rear and suffered a herniated disc at L3-L4 and L5-S1; surgery to repair a deviated nasal septum and right and left TMJ displacement with arthroscopic surgery recommended.  The defendant’s insurance policy was $250,000.  This case was settled at a settlement conference in Nassau County Supreme Court for $225,000.00.