This case involves a male who was hit from behind in an automobile accident and required significant therapy and ultimately surgery. The patient had suffered a neck injury as a child, which had required the same surgery to treat. The plaintiff was an uninsured motorist, and his claim was denied since the surgery was characterized as a repair of a previous surgery. However, the defendants allegedly did not due diligence the specific injury; they did not look into where it was, if it was at the same level of the spine, and they did not contact the treating physician to discuss the injury.
Question(s) For Expert Witness
- 1. Please briefly describe your experience adjusting claims like the one mentioned above.
Expert Witness Response E-044264
I have adjusted or supervised tens of thousands of these preexisting injury cases. It is incumbent on the claims person to focus on whether the accident dynamics caused a new or aggravated injury. Basic adjusting 101 requires one to look past the fact of an old injury, to the specific location of the new one. It is fundamentally unfair and in bad faith not to question whether the new accident caused injury at a new level or even at the same, in the form of an aggravation. I was a claims adjuster/supervisor/executive for 34 years. The last 24 years were spent in a claims/legal position with responsibility for monitoring good faith claims handling as part of my role.
Expert Witness Response E-078468
The brief overview provided does raise a number of possible concerns about the handling of the claim, particularly the adequacy of the investigation and whether an “outright” denial was reasonable. Even if the accident caused an aggravation of a pre-existing injury, that aggravation should certainly be considered. I would need to learn more about what was (or was not) done, but would be looking generally at: attempts made to obtain info about previous surgery and why it was performed, attempts to obtain documentation of any periods of continuing treatment or problems over the 20 years between that surgery and the MVA, attempts to obtain an explanation from treating physician about how the injury was or was not an aggravation of the prior injury, and why an IME or medical record review was not performed.