Here is a summary of a recent call I had with an injured worker that made him think I was a mind reader or could predict the future.
Worker: I injured my hip when I fell on a floor on to my side and tore my labrum. This was six months ago.
Me: I’m sorry to hear that. What’s leading you to call a lawyer now.
Worker: I got an injection and some physical therapy and ..
Me: Sorry to cut you off, but let me guess, the doctor wants to do surgery, but the insurance company has denied it.
Worker: How did you know that? And they also won’t tell me why it’s not approved, but said I would get a letter that I haven’t gotten yet.
After assuring him that he didn’t accidentally call the insurance company, we had a nice talk about it. I am no genius and I can’t read minds or predict the future. What I can do is notice patterns that happen on case after case.
What Is A Common Insurance Company Tactic On Illinois Workers’ Compensation Claims?
The bigger your injury is and the longer you have gone without getting an attorney, the more likely it is that the insurance company will try to thwart your case without reason. Having a hip surgery or similarly big surgery like a fusion costs a lot of money. It can easily run into the six figures.
So for an insurance company there is literally no risk in telling you that they won’t pay for it. Their hope is that you will choose to use your own personal insurance and that they can avoid the big expense. When he gets the letter it will not be very descriptive, but will say something along the lines of “We have reviewed the medical information provided and have determined your surgery does not meet the blah, blah, blah.”
It’s all nonsense. The only way they do things differently is when they send you to a hired gun IME to say you are fine or your need for surgery isn’t work related.
When you tear your labrum in your hip, it is a serious injury. If after many months you are still in pain and physical therapy and injections don’t work, the next step is surgery.
The silver lining is that this is a problem we should be able to solve rather quickly. In fact, the insurance company can be punished for their unreasonable delay and denial if they don’t roll over quickly or come up with an actual valid reason for their actions.
My guess is that they likely consulted with a doctor to review the records and were told that having hip surgery is the next step. So they essentially took a hail Mary approach with the denial and hoped it would work.
This is why I could never be happy representing insurance companies. There is nothing wrong with a good faith dispute based on facts. But putting the health of a person at risk for no reason other than your bottom line is gross and something I would not want to be a part of.
Bonus tip. There are a lot of lazy lawyers who will tell you to just take the denial letter and use your own personal insurance. That can make sense when it’s an emergency or there is a legit dispute. Without that though, your attorney should be aggressive and filing a petition for immediate hearing rather quickly. If they don’t then they might not be fighting for you and you end up spending a bunch of money out of pocket.
