Why Was My Case Denied?

I started off my career working at two different insurance defense law firms. It’s really the best training you can get to be a lawyer because unlike some attorneys for injured workers, defense attorneys worry about what their clients think.  I was taught how to critically analyze a case and look for hidden issues.

I didn’t stick with that side of the business because some of the insurance companies gave me the creeps and I like helping, not hindering people.  I did learn a ton though, the most important being how insurance companies think and why they do some of the things they do.  It’s really helpful to any injured worker that contacts me.

One of the things I learned as a young lawyer is that an insurance company will deny a case even if they think that if they go to trial that they will lose.  If you think about it, it makes sense.  Insurance companies make money by reducing the amount that they pay per claim.  If they just accept your case then they will pay the full amount.

By disputing a case, the only potential harm is that if it’s so unreasonable they could be hit with a petition for penalties and fees which is an Illinois Workers’ Compensation Commission rule that is meant to deter bad behavior by them by adding penalties up to 50% of the amount that is wrongfully denied for medical care and daily fines for improperly denied TTD benefits.

The problem is that once these penalty motions are filed, very few lawyers with good cases follow through with them because the insurance company will roll over if they have no leg to stand on.  If they have any possible defense then a penalty petition isn’t a worry.

In most cases the insurance company or their lawyer will make an analysis that says something to the effect of “we have an 80% chance of losing this case if we go to trial.”  To them that means there is a 20% chance of success, so giving you everything you want is a bad idea.

A recent call to my office highlights this example.  A worker fell on some stairs at his job, but didn’t know what he fell on.  The law in Illinois says that if you have an unexplained fall then your job isn’t responsible for work comp benefits.

A closer look though shows that this worker was rushing to a meeting and carrying a binder.  Supposedly a recorded statement asked him if he knew what he slipped on and he honestly said no.  That was all the insurance company needed to deny the case.  They didn’t ask him further questions that would indicate why he fell because that would have made the case go from a winner for them to a loser.

So they’ll deny the claim and a penalties petition would likely fail.  In the end they will probably lose, but if this worker doesn’t hire an aggressive attorney, they might end up settling for 75% of what the case is worth.

And that is how insurance companies make money by screwing people over.  Sometimes they get even luckier and the worker gives up or puts the claim through their own health insurance.

It shouldn’t be, but often these cases are a game to them and they are good at playing it.  If they can find ANY REASON to deny your case they will and sometimes they’ll do it with no reason if they think you might not do anything about it.  Don’t freak out.  Just get someone in your corner who knows what they are doing and how to navigate the system.