WPI & Pr-existing Conditions
WPI, Pre-Existing Conditions, and Future Medicals
Adjuster Assertion: Challenging Expert Medical Assessments Without an IME
Adjuster Assertion: The adjuster disputes the treating physician's assessment without conducting an Independent Medical Examination (IME).
Zap Response:
Without an IME, the adjuster lacks the medical authority to refute the treating physician's findings. Courts generally uphold the treating physician's expertise, as they have direct insights into the claimant’s condition and necessary treatments. Below are key points to refute this assertion:
- Reliance on Treating Physician’s Expertise: Treating physicians, through direct care, have the most reliable insights. Absent an IME, any attempt to refute these findings is speculative and lacks medical authority.
- Case Law Support: The federal case Richardson v. Perales, 402 U.S. 389 (1971), emphasizes that firsthand medical evaluations constitute substantial evidence. Adjusters cannot credibly dispute findings without an equivalent evaluation.
- Standard of Medical Necessity: Arbitrary reductions without an IME may violate the Unfair Claims Practices Acts (UFCPA). Industry standards require expert testimony to justify treatment-related disputes.
- Inadmissibility of Non-Expert Opinions: Courts routinely exclude non-expert opinions on medical treatment. Adjuster opinions, unsupported by an IME, would likely be inadmissible in litigation.
- Re-Aggravation of Pre-Existing Conditions: The eggshell plaintiff doctrine requires claimants to be evaluated as they are, without penalization for vulnerabilities. Attempting to reduce claims based on pre-existing conditions contradicts this principle.
Adjuster Assertion: Future Medical Assessments Are Speculative
Adjuster Assertion: The adjuster disputes the necessity or cost of future medical treatments, claiming they are speculative or unsupported.
Zap Response:
Future medical costs are clearly documented and based on professional medical recommendations. Disputing these costs without evidence or justification undermines the treating physician’s expertise and violates fair claims practices. Key points to address:
- Reliance on Treating Physician’s Projections: The treating physician has outlined future treatments based on their direct care of the claimant. Absent an Independent Medical Examination (IME), there is no basis to challenge these projections.
- Medical Necessity and Documentation: The future medical costs are supported by:
- Medical records showing the claimant’s ongoing treatment needs.
- Projections of treatment frequency and costs, derived from established medical standards.
- UFCPA Compliance: Reducing future medicals without documented evidence violates the Unfair Claims Practices Acts (UFCPA). Industry standards require insurers to justify all reductions with factual evidence.
- Inadmissibility of Non-Expert Opinions: Adjuster opinions on the necessity of future treatment lack the qualifications required for admissible medical testimony in court.
- Litigation Risks: Failure to account for documented future medical costs may result in excess judgment liability and exposure of bad faith practices during litigation.