What can I do if 2 insurance companies each say the other is responsible to pay my claim so they both deny it?
I live in California, btw. So what happened is that I was taken off work due to extreme stress. There was no doubt that I really needed time off and was having a lot of physical and emotional symptoms due to the stress. It was mostly work-related, and I was taken off for almost three months. Even the man who interviewed me from the worker’s comp insurance company agreed that the conditions under which I was working were horrendous. However, the worker’s comp insurance company denied me, saying that more than 50% of my stress was due to factors outside of work.
So then I went to my private disability insurance company, and they denied me saying that worker’s comp was liable, not them. So I’ve been struggling financially because neither company wants to cover my loss of wages. I’m back at work and it’s improved a little, so I’m catching up on bills. But still, I need that money back. What else can I do? I already appealed once to the private insurance company and they denied it again. Is there some third-party that can investigate and decide which company should cover the claim?
Oh and I should mention that I don’t pay into state disability because I am a teacher. So it’s a private insurance company that I’m dealing with.
You might want to speak to an attorney. Most attorneys don’t charge for a consultation. Good luck
YES… a WC claim would be possible, and compensable. When you are
denied benefits/acceptability of the claim, you MUST have medical
evidence to support that. Your Dr must certify your eligibility for
the WC wage loss benefits, in your case, you MUST have 51% of your
stress attributable TO your job. When the carrier denies liability,
you go to PQME..a panel of Dr’s, QME’s would be proivded, you
select one and that Dr will provide a medical/legal opinion on -the
-AOE/COE standard..that the injury/illness Arose Out of your
Employment, and in the Course Of performing your job
duties/Employment. So…at this point, if it’s not too late, you
MUST request the PQME process, and, discuss your issues with a
competent WC attorney. You can also get help from an Information
and Assistance officer at the WCAB…look in the phone book for
this information. The WC CA/claims adjuster should have provided
you with the information on how to dispute their denial of your
claim… LOOK at the letters you rec’d. DO NOT miss the time frames
to dispute this…you will forfeit benefits.
Attorney. At this point there is no other answer.
You can try to file a complaint with the Department of Insurance. But the real answer is to get an attorney.
You are a teacher employed by a school and the school is not doing anything to help? I will think that the HR department of the school should step in when you took the 3 months off. I believe it depends on the official reason that you took this 3 months off. Is there a doctor’s letter or report saying that it is due to work stress or you took it on your own free will? If it is you own decision and not ordered by a doctor, it is tough to get any compensation from any insurance. Get the facts sorted out and get your school to help. I am not residing in US and I am not sure of the rules there so that’s all I can offer, hope it helps.
Generally, workers comp doesn’t cover a non-injury related stress/emotional/mental health claim.
Since you HAVE private disability coverage, and they’re clearly trying to weasel out of this, what you need to do is file a complaint with your state insurance commissioner. Clearly, since workers comp denied the claim, it’s not work related, and your private coverage should be paying.
Have to disagree with mbrcatz on this one… because the WC carrier
denied the claim does not mean it is the fact the ‘stress/psych’
injury/illness is not in fact due to AOE/COE…employment and job
duties. It simply means they have denied the claim. At this point,
a PQME/AME would be the first step in litigating the claim. The
STD/LTD carrier would always be secondary to a WC claim, SDI, or
even SSDI. Claimants must exhaust the ability in pursuing any/all
other benefits there may be eligibility to. That includes
litigation of the WC claim before a judge with the authority to
award benfits…WC or STD/LTD. This OP must pursue this claim in
the WC courts to determine compensability.