There are often situations in which a claimant will have previously suffered an injury or disease process in the same location as he/she recently suffered a new work-related injury. In these cases, the insurance company will often seek to lay the financial blame for the current injury on the old injury. In that way, the insurance companies hope to escape liability for some or all of the costs related to the present injury. If this has happened in your claim, you should seek legal representation immediately.
Also important to understand, the insurance company for a claimant's current employer may not actually be responsible to pay for the entire expense of a current injury (including the salary the claimant may be losing presently due to the new injury). For instance, if the claimant previously had a different work-related injury in the same location, the current employer's insurance company may escape some or all liability. This is so because under relevant statutes, the employer may be able to shift liability to a different insurance carrier. Again, there are technical ramifications, and you should seek legal counsel immediately if you have such a complex claim.
Finally, claimants should be aware that sometimes an insurance company may be willing to "only temporarily" concede a particular dispute within a complex claim. This can work to the claimant's advantage, especially when seeking medical treatment. In such cases, a stipulated agreement may be reached between Attorneys for both the claimant and the current employer's insurance carrier. Such an agreement can be made on a "temporary" basis, "without prejudice" to future judicial findings.
For instance, an insurance company may dispute the need for a work-related knee surgery based on radiographic evidence of an underlying arthritic condition. The underlying arthritic condition may have been caused by a previous work injury, or even by natural process. The claimant's doctor gives an expert medical opinion that a recent twisting injury at work is what makes immediate surgical repair "medically necessary." A previous employer's Workers' Compensation insurance carrier agrees with the claimant's physician. The current employer's Workers' Compensation insurance company obtains its own IME physician who states that the underlying arthritis is the only reason surgery is now necessary, so the current Workers' Compensation insurance company should not have to pay for the operation, subsequent rehabilitation, or for lost wages during the recovery period. Meanwhile, the claimant's private health insurance plan refuses to pre-authorize the surgery because it knows it cannot be held liable in New York if the injury truly is related to the claimant's current or past work. Every doctor in the world agrees that the claimant needs knee surgery now, but no insurance carrier will agree to pay for it because each potentially-liable insurance company knows it has a very reasonable chance to avoid the massive associated costs.
Under such circumstances, operative reports from the requested surgery may eventually prove the decisive evidence necessary to resolve the claim one way or another, and therefore, to determine which insurance company (or companies) will ultimately be held liable. Here, the current Workers' Compensation insurance carrier may be willing to pay for the knee surgery for the time being, just to get a look at the eventual operative report. If the operative report supports the contention that the medical necessity for that operation was not caused by the current work-related twisting injury, the current employer's insurance company will be on much better grounds to both defeat the claimant's current Workers' Compensation claim, as well as to either seek reimbursement from the claimant's private health insurance plan, or from the Workers' Compensation carrier from the claimant's previous employment.
Under such circumstances, if the current Workers' Compensation carrier can be sufficiently assured that the question of liability will not be conclusively resolved merely by the initial payment for the surgery, a deal can be arranged whereby the claimant gets the necessary operation immediately, and liability for the operation is decided or litigated thereafter. This is truly the most compassionate result for the claimant needing immediate surgery, but the complex nature of the claim may mean that an unrepresented, uninitiated claimant is unable to broker such a deal.
Again, if you have suffered a new injury upon the same site or location or bodily system as you have suffered a previous injury or illness (whether work-related or not), we advise you to seek legal counsel immediately. These are among the most complex and overly-litigated claims. Certainly, if you are in this situation, Contact Us for competent representation.
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