By Fred Lewis and George Casper
As we have touched on in previous entries, there are times when an injured worker’s claim for worker’s compensation benefits is denied by the employer’s insurance company (hereafter referred to as “surety”). Many injured employees (hereafter referred to as “claimants”) wonder why the surety would deny their claim because the facts all seem to point to the acceptance to the claim. As with many things in life, the surety’s decision to deny most compensation claims boils down to one word: money.
Worker’s compensation sureties normally receive contractual discounts on the price of medical procedures. However, the discounts given to a claimant or a claimant’s personal insurance are far greater than the discounts given to a surety. Knowing this fact, worker’s compensation insurance companies or sureties will be tempted to deny the claim initially. They understand it will likely be found compensable by the Industrial Commission. The sureties will then come back years or months into the case and attempt to compensate injured workers by settling for a compromised amount based on the contractually adjusted amount the claimant’s insurance company makes with the medical provider. There are many previous cases that plainly state sureties cannot use this tactic and must pay the full invoiced amount (more than their contractual agreement amount if they accepted the game at first) of a medical procedure if they deny the claim. We will highlight three: Sangster v. Potlatch Corporation, IC -01-008322 (2004), St. Alphonsus Regional Medical Center v. Edmonson, 130 Idaho 108, 111, 937 P.2d 420, 423 (1997), and Neel v. Western Construction, 147 Idaho 146(2009)
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