When Insurers Interfere With the Medical Care You Need From Your Claim

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Some of our workers’ compensation cases come to us reluctantly because they like their employers and fear causing trouble for them.

During a free consultation with us, a special education teacher who had been assaulted by a student was reluctant to challenge the insurance company’s insurance adjuster about her claim, although she was still missing work.

The thing is: The people who manage your claim, the adjusters, are not medical doctors, although some of them may act like it.

Keep in mind that you are not suing your employer when you talk to an attorney. You are simply finding out what your rights are under New Jersey law and how to protect yourself.

Doctors Who Work for Insurers Are Not Your Best Friends

doctor meeting with patients

The process can be trying for injured workers. The insurer’s authorized doctor who you are required to see is hired by the insurance company and may be reluctant to get you all the care you need.

By asserting influence in your medical treatment, the adjuster may place subtle pressure on the doctor to keep costs down. Doctors know that if the adjuster disagrees with their medical opinions too frequently, the insurance company can simply stop referring injured workers.

This creates a potential conflict of interest for the doctor, who may want to help you as much as possible but is also aware that he or she may lose further referrals if the insurance adjuster disagrees. Simply that conflict can be enough to make the authorized doctor inclined to provide less expensive treatment first.

This is why you need to be informed about the claims process in NJ and what your rights are. Nobody—besides an attorney—will look out for your legal rights when you’ve been injured.

Second Opinions Can Help, but Also Hurt

patients meeting

If there is a dispute about what care is needed, your attorney can file a motion, accompanied by a doctor’s opinion, saying what treatment is needed. That doctor may be the doctor authorized by the insurance company or someone who your lawyer retains on your behalf. Based on this, the judge may ask the parties to agree to an independent medical exam that the insurance company pays for, or may simply order that the treatment be provided based on the records in front of him or her.

Another thing that may happen is that the adjuster may also ask for an independent medical examination because he or she disagrees with the authorized doctor. You’ll have to comply, or risk having your claim denied.

Note that this doctor may have a conflict too, because the doctor is also compensated by the insurance company and chosen by the adjuster.

You have a good chance of winning however, if the so-called “independent” doctor disagrees with the first diagnosis. So don’t give up.

Remember, don’t let your insurance adjuster think he or she is your doctor and dictate what care is right for you.