Legal Question in Personal Injury in New York
Insurance company denial
What are my options when an insurance company sends me for 3 consecutive I.M.E's and all the doctors state I can go to work? They denied me certain doctor coverage and Medicare is picking up the bill.
I just had a lumbar fusion and decompression with instrumentation due to this accident.
As Medicare is going to want their money back,can I go after the insurance company via bad faith insurance attorney or simply state my case through arbitration and provide the necessary medical documents to support my stance.
Can Medicare,at its option,take the insurance company to court?
Customarily,will Medicare accept an insurance company's doctors records over my current doctor records?
2 Answers from Attorneys
Re: Insurance company denial
New York has no-fault arbitration procedures, where you can appeal the denial of no-fault benefits. It is unclear from your post the exact basis for the denial (i.e., pre-existing conditions, full recovery, etc.), but assuming your treating physicians state otherwise and set forth a clear basis for your injuries being related to the accident, you may be in a position to overturn that decision by the no-fault carrier. Medicare has a lien on your recovery (again, I am assuming you have a personal injury action pending), and while they could go after the no-fault carrier for reimbursement, they don't need to. If you do have a pending lawsuit, is your current attorney dealing with the no-fault situation, since he or she has access to all of your medical records?
My firm regularly handles these matters and I would be happy to speak with you further to answer any other questions you may have.
Re: Insurance company denial
A primary goal of an Independent medical exam is to provide the insurer with a basis to stop paying for treatment. Usually if you have had surgery they cannot deny post surgical care, but they will normally attempt a denial based up your having reached "maximum medical benefit;" in other words, that there is no additional treatment thatwill make you any better then you are.
That and exhausting the first party benfits (minimum is $50,000) are the easiest ways for a company to deny bills.
After surgery,if you are still treating as a result of the accidnent, and your other physician
has a different opinion you have to file for arbitration with the Insurance Dept. through the American Arbitration Association.
However, if no fault denies and the arbitrator rules in their favor, I don't believe that Medicare will hold you responsible for the bill.
They may send you for an IME as well to determine what their own doctors think.
There is nothing you have described that amounts to bad faith. Perhapsd you have not completely explained?
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