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Joseph, Lawyer
Category: California Employment Law
Satisfied Customers: 5299
Experience:  Extensive experience representing employees and management
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I made a workmans comp claim in April 2012 for an infection

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I made a workman's comp claim in April 2012 for an infection in my knee. I had been working on a deck at my house for 3 weeks. At the end of the 3 weeks I was at work at an Auto Repair shop and walked into a Dairy truck hitch. About 1 week later I had to go to the Emergency room with a swollen leg and redness. When I arrived at the hospital I told the DR. that I had been working on my deck and I thought it was just sore, at this time I also told the Dr. that I had ran into a hitch earlier in the week that caused 2 small puncture wounds. The Dr told me it was infected and had come from the 2 puncture wounds the hitch had made. After a few weeks the Claims adjuster sent me a letter denying my claim. He stated that I had not seen a QME medical examiner, but he never requested me to see one in the initial packet. So I went through that process and again later a letter saying he denied it because the QME did not send him the report. So then I received the QME report in the mail and it confirms my complaint, that a splinter of wood could not have caused this, therefore the hitch caused it. Today I received a 3rd letter of denial and the claims adjuster says that I told the hospital one thing and my employer another, and that the QME report had no bearing on this. All that being said, they have already paid the hospital bill, which is all I wanted in the first place, and they are now offering me a $5000 settlement. My questions are this: If I accept this settlement will I now be flagged as a fraud in California? If I accept this settlement do I have to pay back the hospital what the insurance has already paid? Do I have to pay back the insurance the hospital bill? I am not sure why they have offered me this in the first place, I just wanted the bills paid. I am back at work and my leg is completely healed, so I don't foresee any further medical care from this injury.
Not sure where to go or what to do at this point. I did not think I needed a lawyer, but now I am starting to think I do.

Submitted: 4 years ago.
Category: California Employment Law
Expert:  Joseph replied 4 years ago.
Hello and welcome to JustAnswer.

My goal is to provide you with excellent service this evening.

In answer to your first inquiry, you will not be labeled as a fraud if you accept this settlement. It would have no bearing on anything outside the current workers' compensation case.

If they are offering you a $5,000 settlement, that would be in addition to the hospital bills that have already been paid, so you would not have to pay back the hospital what the insurance has already paid.

It would also not be necessary to pay back the insurance for the hospital bill amount.

The settlement amount is likely being made to bring closure to the case and ensure that there will not be any further litigation if you were considering hiring a workers' compensation attorney.

Since their legal costs would exceed $5,000, and they want to compensate you some for pain and suffering (as well as missed work), that is why they are likely offering you the $5,000 settlement.

I hope the above information is helpful. Since my goal is to provide you with the best service this evening, please don't hesitate to ask for any additional information or ask any follow up questions.

If not, please remember to rate my answer positively so I get credit for my work!

Thanks and best of luck!
Customer: replied 4 years ago.
Why would they pay the bills before denying the claim? Why would I litigate any further if the bills were already paid and I have never asked for anything more than that?

Expert:  Joseph replied 4 years ago.
Hello Bob,

Did they decide to pay them before or after denying the claim? I assumed they have decided to accept the claim now, which is why they paid for your bills. Otherwise, those do seem like incredibly strange business practices and I'm not sure what their motivation would be, if any.

I'm also not sure why the company would offer you a settlement offer based on your requests, but it could have something to do with their initial denials of your valid claim, as well as the potential that you could file a workers' compensation case with an attorney (even though you never indicated you wanted anything more).

I can only speculate on the answers to your follow up questions.

Even if they have no reason to suspect that you would do so, many companies would rather have the case closed to ensure that they have no potential future liability.

Since you have no desire to file any further claim, I would suggest that you take the offered settlement. However, you can always get a local workers' compensation attorney to review your case if you are still worried.
Customer: replied 4 years ago.
They did pay the entire claim in September of last year after the second denial letter. Then today the 3rd denial. That's why I thought it was strange that they paid it, and I still get another 3rd letter denying the claim. I will not ask any further questions and accept after this, thanks for you proffesional answers. In California is there a time limit on the insurance company. What I mean is, due they have to pay the bills if they do not accept or deny in a certain amount of time?

Thanks again,
Expert:  Joseph replied 4 years ago.
Hello Bob,

That seems like its probably a bureaucratic error and that they have already accepted the claim as they paid it in September after the second denial letter.

Unless this denial letter is denying some other aspect of your claim.

The statute of limitations for the insurance company to pay the claim is the same on other written contracts, which is four years. However, since the insurance company has already paid, they have already given up their rights to challenge the claim.

If they were still denying that your claim was work related, they wouldn't have paid your hospital bills in September. To clear the issues up, you may want to contact your workers' compensation insurance carrier directly, since it seems that they are a bit on the disorganized side.

I hope this information was helpful, but it does seem that a phone call or email to your workers' compensation carrier would be the best method to clear up this confusion, as it appears the right hand doesn't know what the left is doing in this company.

(Or, you could just decide 'not to look a gift horse in the mouth,' and accept the 5k settlement on top of the payment of your hospital bills, even though you never asked for it in the first place. Too much investigation may result in them retracting the offer).

(Also, no worries about the follow ups).

Thanks and best of luck!
Have a great weekend!
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