Category: Workers’ Compensation

Why can’t the adjuster pay me on time?

Workers' Compensation

In most cases there is absolutely nothing that prevents an adjuster from paying you on time. It’s just a matter of her interest and inclination in doing so.

In some cases when the employer is self-insured they must send money periodically to the insurance company. In those instances we’ve heard adjusters use the excuse that they are waiting for money from the employer but that’s just an excuse. It is the adjuster’s responsibility to make sure she has proper reserves.

More often we suspect that the adjuster is toying with you. She knows that under current North Carolina law the check isn’t due for ten days after the time you missed work. Thus, if you missed the first day of the month the adjuster doesn’t have to pay you until the tenth. What if she doesn’t? Well nothing happens immediately. If she’s fourteen days late – the twenty-fourth- then the Industrial Commission “may” impose a 10% penalty. Thus, if the adjuster sits on your $500 weekly check for three weeks the NCIC might sanction her $50.

Mind you, the Industrial Commission is open to waiving that penalty if the defendants present compelling evidence that they shouldn’t be fined. In the past we’ve seen the Industrial Commission waive the late penalty for reasons which included “I forgot”, “my attorney didn’t tell me to”, and “I put in an order for it to be mailed… something must have happened.” More likely than not the NCIC will impose the penalty but questions certainly remain as to whether that’s a significant deterrent. We’ve had luck with taking a different approach and have obtained orders requiring an adjuster to pay timely. If there is a consistent failure to comply with this order we’ve been able to get sanctions with some teeth to them.

The doctor has ordered a test but the adjuster isn’t approving it. Why?

Workers' Compensation

There’s no simple answer to this but here are a few possibilities. First, she’s lazy or procrastinating or overworked. Maybe.

Second, she’s in denial that the test is actually necessary. She may be hoping that you spontaneously get better without the test. That occasionally happens but not often. Most experienced workers’ compensation doctors aren’t just ordering tests randomly. They don’t order tests they don’t think are necessary. But some adjusters act like they know more about modern medicine than someone who went to medical school.

Third, she may have an internal review that has to be done before the tests can be authorized. Some insurance companies have an internal “utilization review” performed by an in-house “doctor” to second guess the doctor who ordered the tests.

Fourth, the adjuster may be trying to line up a second opinion with another doctor who may say the test isn’t necessary. You may ask yourself: would an adjuster really pay an extra month of weekly benefits, pay hundreds of dollars to a rehabilitation nurse to set up a second opinion, and pay hundreds more outside of the Industrial Commission medical fee guidelines, just in the hope of avoiding a $750 test? The answer is yes.

Why does the adjuster have to get a second opinion when her own doctor has recommended surgery?

Workers' Compensation

She shouldn’t, but under the current set of laws there really isn’t much of a limit to what the adjuster can request. It rarely works to simply refuse to attend a second opinion. On the other hand we’ve had some success convincing the Industrial Commission that the adjuster is abusing her privileges. And under a law which escaped revision by Gov. McCrory if an adjuster wants a second opinion on a surgical recommendation she must move quickly. While the Industrial Commission generally grants additional time the law requires that the second opinion be scheduled (but not necessarily completed) within ten days of the original recommendation for surgery. We are very aggressive about scheduling expedited hearings over this issue.

Can the adjuster really send me halfway across the state to see a different doctor?

Workers' Compensation

Sometimes, and, if they can get away with it. A while back a well-known neurosurgeon based in Raleigh spoke at a closed-door meeting with adjusters at a meeting sponsored by a law firm, which represents mostly insurance companies and employers. During the course of his presentation he stated that he believed a lot of injured workers underwent unnecessary surgeries and ended up being out of work longer than necessary as a result. What happened next? Clients who lived in Mount Airy, in Lexington, even in Charlotte were being sent to him for second opinions.

This happens more often than you would believe. In this particular case we objected to the Industrial Commission. The defense attorney, coincidentally a partner in the firm that sponsored the private meeting, argued that the law regarding second opinions didn’t require that the doctor be fair or neutral. The only limitation was in terms of geographical reasonability. The Industrial Commission seems to have bought into this theory. Your best defenses against a second opinion are that it’s too far away and that the adjuster has already had a couple of second opinions. At some point the adjuster has to concede that she’s only shopping for an opinion that she wants to hear and isn’t really looking for sound medicine anymore. While that seems patently obvious to some people it’s considered bad form to admit to it when you’re at the Industrial Commission.

To be fair, we have our own lists of doctors as well. One advantage of our law firm is that we’ve been keeping records and notes on doctors, adjusters, rehabilitation nurses, etc., for years now. We know which ones tend to unnecessarily favor the employers and insurance companies and we know which ones put their patient’s interests first. So when it’s our turn to pick a doctor we know who we’ll recommend.

Can my employer or the adjuster talk to my doctor behind my back?

Workers' Compensation

Yes. And they do. All the time. They didn’t use to be allowed to do that, but very very often they did anyway. Successful lobbying with Gov. McCrory and the political leaders in the legislature lead to a huge change in the law. Now employers can talk to your doctor but are not required to tell you immediately that the conversation occurred or what the details of the conversation were.

Is this necessarily bad? While we doubt that doctors are engaged in conniving with adjusters we don’t really understand what all the secrecy is about. The old law required the adjuster or employer to write to the doctor but to let the injured worker see the letter before it went out so that they could ask for anything to be added. That seemed really fair. Why did insurance adjusters and employers want this changed? It doesn’t seem to be an exaggeration to say they must have had a motive if they were going to lobby the government to change that requirement. So it’s fair to say that they specifically want to be able to communicate with the doctor.