Medical Care Denials
Garfinkel Schwartz has fought as a plaintiff’s attorney to help injured and ill military civilian contractors and Longshoremen fight medical care denials and compensation on behalf of civilian contractors and longshoremen since 1976. The same group of insurers tries to do the same exact things to everyone for profit.
Insurers don’t make money if they approve unlimited medical care and compensation. It’s a clever business … betting that no one will get sick or get hurt. To When a military contractor or longshoreman is severely injured, the insurance company is Johnny on the Spot monitoring and trying to control the medical care.
Don’t Be Fooled
If you’re injured and sent to the hospital for emergency care, the tact of “being there for you” with doctors and nurse practitioners, case managers, may seem like the insurance company has a concerned team in place to help you, to “support you” through the medical process.
They’re right there so that they can monitor costs, care, options that are in the best interest of the insurance company. This is why we warn clients to be prepared for denials, cuts in checks, because we know what insurers are capable of.
We chart their tactics—we know all their tricks and we’re never surprised because the industry inherently earns money by taking premiums and payments and not paying a claim.
Don’t Be Surprised
There’s nothing we haven’t seen an insurance company try to do to a civilian contractor or to a Longshoreman who was injured or became ill on the job. You may be surprised when you open a check and it’s cut by two thirds or a half without warning.
Garfinkel Schwartz is never surprised.
This isn’t a battle you want to fight alone by going through the proper channels. Because while you follow the rules, complete the paperwork requests, call back, answer questions honestly, jump through every hoop they present. In the end, they will not do the right thing. Your claim will be denied because they’ll know you don’t have an attorney.
What is a Peer Review?
The insurance companies hire a doctor of their choosing – a peer — to review your medical information.
This Peer Review doctors can be a deciding factor in whether you get benefits that YOUR doctors are ordering for you to recover, rehabilitate, be treated and be well and comfortable.
But They Never Meet You
A doctor hired for a peer review never speaks to you, sees you, or even calls you. You won’t know when it happens or that your records are being reviewed and analyzed.
However, a peer review is used by insurance companies to cut your medical care and benefits off. It’s the right of the insurance company to cut those benefits so that their business makes money.
What is a Labor Market Survey?
Insurance companies perform labor market surveys so that they can find you jobs to work that are based on your physical and mental ability to perform a job. It’s their assumption that you are able to do the job so they can reduce your earning capacity benefits.
Using Department of Labor federal data they’ll line up positions they think you should qualify for and can work to become employed and decrease your benefits.
The insurance companies will try to prove that yes, you can do the job physically and that based on your experience and education you can do the job.
How Do You Deal With These Dirty Tactics?
It sounds bad: the insurance company is going to cut off your benefits. What are you supposed to do and how do you fix this problem?
You’ll have to call a lawyer because there’s been a Labor Market Survey and a Peer Review because both are tactics used to cut your benefits.
You won’t know until your check comes one day with a lesser amount, maybe half, maybe more will be deducted.
The only thing you can do to prepare is to call a Defense Base Act Lawyer. Get to know him or her and they’ll represent you after basic paperwork. You don’t pay attorneys fees and you don’t have to worry, an experienced Defense Base Act Law firm will immediately begin the process for returning your benefits.
How Long Does it Take to Get Benefits?
The answer to the question “how long it takes to get benefits?” is not easy. In general, every case differs and you should be ready to wait.
Garfinkel Schwartz works immediately upon receiving your paperwork signing on as a client.
It is not easy fighting insurance companies, especially when you’re sick, you’re in the hospital, you’re at home or your taken by surprise from the tactics insurers use to deny your claims. Don’t try to make your family fight for you: they’re already caring for you and need to continue to help you get healthy.
Call a Defense Base Act Lawyer. It’s always good to talk to several so that you can really find out who will be able to work best with you. Experience matters and so does the plan and the answers that you get. You have to be comfortable with your lawyer.
We know what insurance companies are capable of and have seen it over and over and over again. They can do it, they will do it and it’s only a matter of time.
Tip-Offs That a Denial May Be Coming
We always want to share with civilian contractors, sub-contractors and longshoremen the importance of having an attorney to handle all DBA or Longshore claims.
Insurance companies will never be profitable if they’re paying you or giving you health. Their ONLY goal is to eventually deny, deny, deny.
You may think that a lawyer will complicate matters or that it will cost you a fortune. Neither is true: all legal fees are paid and you don’t pay a penny—ever. A lawyer will protect you, protect your compensation, your medical care.
An experienced Defense Base Act attorney will fight for your case. Your attorney will help you complete paperwork, will prep you for your legal meetings and will be there to fight and defend you in court and in depositions and hearings.
Here are some words that if you hear them at any time from an insurance company should prepare you for a fight ahead. We’re not trying to scare you, we want to prepare you so that you can hold onto and keep what is yours under the law.
You have to cooperate with the insurance company requests so don’t ignore them. However, do not talk to them until you’ve talked to a lawyer.
Don’t go into meetings by yourself and don’t go on the record until after you’ve met with a very experienced Defense Base Act lawyer.
If you have an attorney there’s nothing to worry about because the attorney will prep you and help you through every step.
If you’re by yourself you should not try to work anything out with the insurance company. There is no reason to try to negotiate with them. You’ll be at a disadvantage and you’ll be up against insurance companies which one of the strongest business entities anywhere.
You’re smart and you’re clever but you’re no match for some of the best insurance company attorneys in the world.
Here are the phrases to listen for so that you can be on the alert that there is a problem in the near future. Your compensation may be at risk or you may soon have a cut in your compensation. You should be clear and understand that you have to cooperate but you should not go with whatever they say.
“I’m Your Nurse Case Manager” = This person works for the insurance company. It’s their job to get you back to work as quickly as possible with the least amount of cost whether it’s in your best interest or not. Money and cutting costs is the only thing that matters.
“We need a Recorded Statement” = This means the insurance company is ready to deny your claim and wants to begin by getting your statement to see if they can find a reason.
“Independent Medical Exam” = This doctor works for the insurance company and is not on you or your doctor’s side. They will try to find cheaper options to cut medical costs on your care.
“Vocational Assessment” = The insurer wants to find out what you can do physically. You’ll go through physical tests to see what you can do. The goal is to observe you from the moment that you arrive. They are watching you to see if there is any exaggeration or attempt to fake an injury or illness. The insurer often begins surveillance when you begin taking compensation. This is even more likely after this assessment is done. Do your best, be honest and make sure that you explain what you can and can’t do physically.
“Peer Review” = A person who is not a doctor reviews your paperwork without even seeing you, or talking to a doctor. Their goal here is to deny your claim.
“Labor Market Survey” = They find a job you CAN do, now. They’ll interview you and they’ll want to know your entire work, education, training and medical, psychological capability. Your attorney can be with you to make sure that they don’t ask any questions that are out of line.
“Functional Capacity Evaluation” = are you faking or exaggerating? They ARE watching you: Surveillance is common and they’re fast on how quickly they can catch you. You may limp one day and maybe they see you rush to your car in the rain. If your insurance provider sees this and catches it on camera it can be taken the wrong way. This is where your attorney can be take the wrong way.
“Initial Written or Oral Statement:” they grill you about statements. The only thing that you can do at this point is to call an attorney because you want to be protected and make sure that you meet with an attorney to begin telling them about your situation.