Oakland, CA asked in Workers' Compensation for California

Q: Is it legal for an insurance company to stop paying benefits without medical validation by challenging their own doctor?

The insurance company sent letter challenging their own doctor's latest diagnosis and asking for QME. They have also stopped the biweekly payments abruptly which they did not even mention in their letter. I complied with the QME procedures which might take months to fully take its course and without my benefits, I am getting behind in the rent and my bills are piling up. Do not the insurance companies need to fulfill their financial obligations till the QME is decided? Otherwise what are my options, considering that their doctor did not gave me clearance to go back to work, consequently I can not go back to work obviously. In addition to the legal option, aren't medical insurance company accountable also to some state regulatory agency that oversee their conduct?

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3 Lawyer Answers
Ronald Mahurin
Ronald Mahurin
Answered
  • Workers' Compensation Lawyer
  • Point Arena, CA
  • Licensed in California

A: Who is going to punish the Insurance Company? File for Penalties

File for an Expedited hearing and use the PTP reports to justify continued payments of TTD.

James L. Arrasmith
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Answered
  • Sacramento, CA
  • Licensed in California

A: If an insurance company stops paying benefits without medical validation by challenging their own doctor, this may be a violation of the terms of the insurance policy and/or state law. Insurance companies have a legal obligation to act in good faith and deal fairly with their policyholders.

If the insurance company has challenged their own doctor's latest diagnosis and is requesting a Qualified Medical Examination (QME), you may be required to comply with the QME procedures to determine your eligibility for benefits. However, if the insurance company has abruptly stopped paying benefits without explanation, this may be a breach of the insurance contract and your rights as a policyholder.

If you are experiencing financial hardship as a result of the insurance company's actions, you may want to consider seeking legal assistance to protect your rights and explore your options for recourse. This may involve filing a complaint with the state insurance regulator or pursuing legal action against the insurance company for breach of contract, bad faith, or other legal violations.

In addition, it's important to note that insurance companies are typically subject to state regulatory oversight and must comply with applicable state laws and regulations. If you believe that the insurance company has engaged in unlawful or unethical conduct, you may want to file a complaint with the appropriate state agency or seek assistance from a consumer advocacy group.

Overall, it's important to seek out the guidance of a qualified attorney or legal professional who can provide guidance on your options and help you navigate the complex legal and regulatory landscape of insurance disputes.

Nancy J. Wallace
Nancy J. Wallace
Answered
  • Workers' Compensation Lawyer
  • Grand Terrace, CA
  • Licensed in California

A: NO! The Labor Code DOES NOT permit the Adjuster to stop TTD payments just because she thinks you aren't totally disabled any longer. SOLUTION: (1) apply for State Disability Insurance -- SDI -- at www.edd.ca.gov immediately, as it takes at least 10 days. EDD will want to see the copy of the letter stopping TTD payments. (2) File a DOR for an Expedited Trial for an order to resume (and pay overdue) TTD. PROBLEM: if you don't know how to file a DOR properly or where or how to file, you'll need an attorney ASAP. This is attorney should be a REAL attorney, not a 'legal assistant' or a 'hearing rep', because you'll need the Attorney til also FILE A PETITION FOR SANCTIONS AND PENALTIES FOR TACTICS TO DELAY AND HARASS. 'hearing reps' aren't expert at those. So when you are interviewing attorneys, insist on a sample PETITION FOR SANCTIONS AND PENALTIES to be emailed or texted...if its a secretary practicing law without a license, she won't have one to send.

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