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claims adjuster decisions Pennsylvania

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  • claims adjuster decisions Pennsylvania

    how can a claims adjuster say a claim is a dead claim because of an accident that took place out of work? They do not even no all the facts about the out of work accident. I keep getting letters that they are not paying the med bills associated with a previou claim because of an accident that happened in my own car on my way to work. What authority do they have without all the facts?

    Thanks as always for any help!

  • #2
    If it didn't happen at work, I can't imagine why they would want to know any facts about it unless it affects a current ongoing WC claim. The only time I have heard of a car accident related to work is one where the driver was answering a work email/call/text at the time of the accident.

    What about the car accident makes you think it was work related?

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    • #3
      No it was not work related. But I have a open wc claim that work comp is now saying it is now a dead claim because of this recent out of work accident. Sorry didnt make myself clear.

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      • #4
        I've been following this for some time. What happened is called a subsequent and intervening accident. Your employer and their carrier are not responsible for medical care that is the result of such an accident, nor the extent to which you are now worse off because of the new accident. The exceptions being that the new accident is so minor it left no effects or affecting different parts of the body than your work accident. The burden here is going to be on you to demonstrate this is the case. Say your original injury was to the shoulder and you later fell on the ice and broke your leg. Your shoulder claim would continue as always as you injured a different body part and another carrier would be responsible for the treatment for your leg. If when you fell on the icxe you landed on that same shoulder and now require medical care to that shoulder, the WC carrier no longer covers this and treatment falls to your health insurance or other carrier responsible for that injury.

        If you still have objective issues which can be disctinctly attributed to your original claim, you can file for PPD. That is separate from covering medical treatment.
        I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

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        • #5
          Ty as always Elle.The car accident in my own car I hurt my lower back I seen.it coming and grab my neck so it didnt get jerked around. But work comp is still saying the claim is now DEAD. And they dont know the whole circumstances..I guess we will be back in court
          SUCH BS
          anyways thank u both I sincerely appreciate you people on hereq

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          • #6
            You need to talk to a good Pennsylvania workers' comp lawyer. I don't know about PA law on this point, but in some states, the intervening accident breaks the chain of causation only if the intervening act was an intentional act, and I imagine your car accident was not intentional on your part. You cannot trust the insurance adjuster to be correct on these things. Their interest is in not paying your claim. Work comp lawyers typically give free initial consultations, so go talk to a couple of them locally and get some advice about your situation.
            Bob Bollinger, Attorney
            Board Certified Specialist in NC Workers' Compensation Law
            Charlotte, NC

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            • #7
              Thanks Complawyer, I do have a GREAT lawyer...but just tired of bothering her.She has not made any $$$$ yet...thanks to a crooked personal injury lawyer 5 yrs ago. All she has been pd is 34% of 46 wks scar money.. When she should of recieved the whole 100%. But she is well aware of whats going on now and basically said what u and the others have told me. So I guess there will be more petetions and court dates coming up.

              It just amazes me how quick thesr claims adjusters are to call a claim a Dead claim without knowing all the facts. Was thinking of telling the good lawyer I didn't need her anymore...glad I didn't. Thank you for your advise Complawyer.

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              • #8
                Complwyr- you are correct that is sometimes true but it is not the case in PA. Now whether this particular accident tips the scales or not is a question for the lawyer and most likely it is going to take a hearing. This is not uncommon and there are sometimes very good reasons for getting the claims on the record at a hearing, even when the original carrier is going to be responsible.


                BTW- in WC the attorneys are paid a % (and that % is set by statute) of the PPD award. It is how they usually get paid. They may set their own fees for personal injury cases or other types of claims they may handle for you, but WC is a different animal.
                I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

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