Q: can I file law suit for bad faith, pain and suffering , malpractice against an insurance carrier , intentional neglect
The claims management company, representing the insurance company, failed to provide a reasonable level of care for the treatment of a crush injury to the lower extremities. They did not offer suitable recovery or rehabilitation pathway that would be typical for a patient with similar injuries. This constitutes bad faith, pain and suffering, and violations of administrative law. It amounts to medical malpractice. Furthermore, there was no fear of reprisal from the claims adjuster, who suspended my benefits after I sought an evaluation of the injury's extent and Maximum Medical Improvement (MMI) with a properly certified Designated Doctor (DD). The adjuster claimed the suspension was due to a missed appointment, but Med Risk confirmed that my attendance was not required for the appointment as it would be done from my records to determine my physical limitation. Moreover, the doctor, employed by the claims company that preformed the evaluation , falsely noted in his report that he had ex
A:
A claim for misrepresentation of the terms of the workers’ compensation insurance policy is really the only potential claim for bad faith by a workers compensation insurer in Texas. Your question does not indicate a misrepresentation concerning the terms of your workers' compensation policy.
Typically, a worker who sustains a work-related injury is limited to recovering workers' compensation benefits if his employer is a workers' compensation subscriber. There is no recovery for "pain and suffering."
An injured worker is free to choose his own medical providers to diagnose and treat his injuries. Those medical providers have the same duty of care to the injured worker as any similar health care provider owes to a patient.
Workers compensation insurers and third-party claims management companies do not have the power to determine what care the medical providers provide to the injured worker. They may contest payment for such care if they think it is not reasonable or necessary based upon the documentation supplied to them by the medical provider, just like a health insurer can. If a disagreement arises over whether specific items, there is a process for resolving such disagreements through peer-to-peer consultation between the workers' medical provider and a similarly trained medical professional advising the insurer or claim mngmt. company. If the two health care professionals still disagree, the issue cam be presented to the TWC for adjudication.
If you as an injured worker did not correctly get diagnosed or treated for your injury, you may have a medical malpractice, a/k/a health care liability, claim against your own medical provider, but not against the insurer or claim mngmt. company. Most importantly, it is not a bad faith claim. It is incumbent on your medical provider to determine the pathway of treatment and to provide to the insurer and its claim mngmt. company the necessary documentation showing it is reasonable and necessary given the nature of your injuries.
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