I will go through and re-read this information, but are you only experienced in worker's comp or do you have experience as an auto claims as well?

If so, maybe you can answer a question for me. I guess my question would also pertain towards the workers comp as well because it is a question about medical. I'm in Michigan, so I understand that the laws might also be different.

I have been in a constant battle with my PIP Claims Adjuster. She ignores me, she doesn't respond and is a major problem sometimes getting a simple answer from her. Obviously, I am trying to get better. I hate the pain I am in, I went through the surgery for the spinal cord implant (twice) trying to improve my condition, I am enduring the epideral blocks right now. I am following all the doctors recommendations. I always send her an email before and after treatments. I sent her a link two weeks ago in regards to a clinic that does "alternative" treatment. By alternative, I am asking to have a "simple" heavy metal toxicity test ran. I found out after having screws in my knee and foot that I was allergic to the metal. I had the allergy testing performed prior to the implant. A lot (well, all really) of my medicines affect my kidney and liver functions. The heavy metals can build up in your body and mimic or show symptoms similar to RSD. Since I am finding no relief from the stim, the injections, the meds, I am starting to question this heavy metal thing. How hard is it to get "approved" for this type of treatment? Does the insurance industry ever consider something like this? I am desperate right now to improve...

Hi Patty,
Do you have a "good" atty on your side?

Ins companies has the money to pay out for the big guns and would rather spend money on atty fees {possibly deductible for them?- not sure on that part of business tax stuff).

Was this your own ins company or the other party and who was at fault?

But either way if you are in major chronic pain - you need to have a good atty on your side.

This was a vehicle that was insured by my employer that he was selling to me. I basically made the payments to the bank for the truck. The accident happened "off the clock".

We were hit head on by another party, but in Michigan (not sure about other states), your personal auto insurance covers your medical (PIP), loss wages, attendant care, etc.

I understand how the insurance companies "work", as far as deny, deny deny. Save money, etc. When I spoke with adjuster's supervisor this afternoon I expressed that, as well as expressed my wanting to get "better" or at least to a point where I wasn't like I am now. I pointed out that she was stating an IME would be scheduled in January - not done, a case nurse was to be assigned in the early part of Feb - not done. I have sent emails, left messages, faxes, etc. He was concerned, especially about the case nurse and how I have an upcoming injection. I also told him that I understand insurance companies, and how busy, blah blah blah, but I also explained my frustrations - the pain, the inability to do things I use to do, the weakness.

I do have an excellent attorney that dealt with the other driver and that side of the insurance. He stated that in Michigan, usually people handle their own PIP, and that if I need him, he would be there. So far, he has provided me the information to dispute their decisions and how to "talk" to them. They have to "deny" or not pay the bills for a period of a time before he can intervene. Right now, he supplies some info, but I thought I would just ask this question here to save some time.

I moved your posts to a thread of your own here - it will be easier to keep track of.

Thanks for moving it. Definitely easier to read.

Well, the IME exam will most likely not be in your favor - the Ins co pays the IME dr so they tend to not find pain or injuries. Unless they are actually honest.

And IME may even totally discredit you & your pain. so don't be surprised if that happens.
If you do see an IME-be aware of everything, make notes afterward, if they do anything that cases you more pain go see you treating dr and have it noted in that file.
get a copy of the IME report so you know what the IME says and make corrections and send to your atty.

The previous knee & screw stuff probably doesn't fall under the care or claim in regard to the accident.

Oh or,
How long ago did all this happen?? or was the knee problem due to the wreck also?
A short time line - don't need specific dates or anything -just a base time frame would help.

While during my claims career I handled not only worker's compensation claims (80%), I did have training and experience in auto, liability, product liability, and medical payments coverages . . . I have no experience with PIP coverage, which in my understanding is a little different in each jurisdiction. If you have an agent who sold you your auto policy, I would sit down with that person and have them go over your coverages and explain what is, and possibly, is not, covered. Auto insurance pays on a loss basis, generally only for treatment of those injuries directly attributed to the accident in question. I could not tell if you were injured on the job while in a vehicle, or have had two injurious accident -- one at work and one on the job. If your injuries overlap there can be complex issues surrounding who is responsible for what.

The first thing I would do is make sure all your correspondence is in writing (or followed up in writing) and sent registered/return receipt requested. That establishes your paper trail of attempts to contact your claims manager if they do not yield results. E-mails are good, but mail can be more effective.

The second step I would take is to involve or at least contact your state's insurance commissioner. If there are any statutes that would compel more communication with you, their office can help. They will not advise on specific treatments so much as facilitate better communication with your claims person or insurance company.

And third, if you are going to retain an attorney, know that once you have legal representation, all of your communication will most likely have to go through the attorney's office. I would never advise for or against getting an attorney. However, I have to share that, from my years in claims I heard more complaints about attorneys not returning claimant's calls than I did about any other communication issue on my claims. Your claims person does not have to take your calls once you have an attorney. This is why I always give several options for breaking up a jam in communication with your claims manager, including contacting their supervisor, memorializing all your contacts in writing, and involving the insurance commissioner of your state, before getting an attorney involved. The process can slow down considerably once you are represented.


As for PIP coverage for heavy metals testing -- I am sorry that I don't know the answer to that.

Thanks everyone! Actually, I have had one IME for this insurance company. Unfortunately it indicated that I do indeed have RSD and that I need assistance with my day to day things. This IME however was done prior to my implant. My implant was a "failed" one in Sept of 2010, as the wires migrated and the battery moved and flipped. There were only a few doctors in my immediate area that performed the surgical lead placement and paddles for the stims, and the only one that was really recommended for this was the one that had done the IME.

I contacted both the insurance company, as well as the letting my doctor and the doctor that was recommended for this, and it was determined not to be a conflict. This is the same doctor's office that 2 weeks post-op was insisting that the pain management doctors consider the epideral blocks asap because the swelling and increased sensitivity, as well as the signs of spreading/flaring.

I guess now the insurance company is going to have to find another doctor to perform an IME at this point. I will see if a "case nurse" contacts me before my appointment on Wednesday for the second block. I don't think it would wise to re-schedule this, as the doctor said that it is a 2 block/2 week interval. I feel that the insurance adjuster had enough time and notice to get this accomplished.

I think I will contact the insurance commissioner for Michigan tomorrow. I have a few more questions to ask, and they did provide help when it came to continual attendant care. The way the policy was written (as well as Michigan's basis PIP laws) is that the insurance company will pay for 3 years loss wages and replacement services. They will be responsible for my injury and related problems for the rest of my life, as well as attendant care as long as it medically necessary and reasonable.

Thanks again for your help. My mind gets fuzzy (I try to email/fax all my interactions with this company, confirming details of phone conversations especially so I don't "forget"), and I forgot about the commissioner.