Claims: Acceptance

Chaney v. U.S. Fidelity & Guaranty, 276 Mont. 513, 917 P.2d 912 (1996) Where Workers’ Compensation Court found that insurer’s failure to accept or deny a claim within thirty days constituted acceptance as a matter of law (see § 39-71-606(1), MCA, and Haag v. Montana Schools Group Ins. Auth., 274 Mont. 109 (1995)), the Court erred in failing to hold the insurer liable for claimant’s present condition. Once a claimant shows acceptance of a claim as a matter of law under Haag, and that his original injury was the same kind of injury to the same parts of his body for which he now seeks benefits, he has met his initial burden of proof. To avoid liability, the insurer must then show that claimant attained maximum medical healing and suffered another injury causing his present condition, not shown in this case.
Haag v. School Dist. No. 1, Great Falls Pub. Schs., 274 Mont. 109, 906 P.2d 693 (1995) When an insurer fails to act on a claim for compensation within thirty days, either by accepting or denying liability pursuant to section 39-71-606(1), MCA, or by beginning payments with a reservation of rights under section 39-71-608, MCA, the claim is deemed accepted as a matter of law.

Barnhart v. Liberty Northwest Ins. Corp. [09/13/16] 2016 MTWCC 12 Where the insurer accepted liability for the claimant’s injury and settled the indemnity portion of the claim while reserving medical benefits, it cannot then un-accept the claim by soliciting a contrary medical opinion.

Engle v. Hartford Underwriters Ins. Co. [12/31/13] 2013 MTWCC 27 Where the insurer paid for all of Petitioner’s elbow treatment from 2005 forward, even when the medical records indicated that the treatments were for various conditions, the Court rejected the insurer’s argument that it only accepted one specific elbow condition and denied all others.

Engle v. Hartford Underwriters Ins. Co. [12/31/13] 2013 MTWCC 27 The Court rejected Respondent’s contention that it had accepted liability for only one specific condition and not the entirety of Petitioner’s elbow problems.  A claims adjuster referred to Petitioner’s elbow problems as “current complaints” and acknowledged that a physician had opined that Petitioner’s job duties had accelerated the natural progression of her underlying elbow disease.  The Court found that Respondent never made a distinction between any specific conditions in Petitioner’s elbow, nor did its acceptance letter indicate that it believed Petitioner suffered from two unrelated conditions. 

Clapham v. Twin City [08/01/12] 2012 MTWCC 27 Section 39-71-606(5), MCA, which specifically limits the remedies available for noncompliance with the statute to attorney fees and a penalty, likewise applies to claims placed under § 39-71-608, MCA.  It would be absurd to hold an insurer who invokes § 39-71-608, MCA, potentially liable for automatic acceptance of the claim while an insurer who simply denies the claim would not face the possibility of this action.

Bell v. Montana State Fund [08/02/11] 2011 MTWCC 23 On a claim for which the insurer previously accepted liability but sent a letter denying a specific medical treatment, the letter does not create the existence of a dispute over liability of the claim in general such that the statute of limitations under § 39-71-2905(2), MCA, would begin to run on the entire claim.
Narum v. Liberty Northwest Ins. Corp. [06/04/08] 2008 MTWCC 30 Where, after reviewing the medical evidence and doctors’ opinions, Respondent accepted liability for Petitioner’s left hip condition and settled the claim with medical benefits left open, and where the settlement agreement stated that the parties acknowledge Petitioner may require a hip replacement in the future, Respondent cannot refuse to pay for the hip replacement surgery, arguing that it is not causally related to Petitioner’s industrial accident.
UEF v. Big Sky Petroleum, Montana State Fund, and Melvin J. Strong [4/29/04] 2004 MTWCC 39 Insurer may rescind acceptance of claim and deny further benefits for fraud or misrepresentation which vitiates the acceptance. Where insurer accepted claim based on an incorrect date of injury which was supplied by employer and did not insure the employer on the date when the injury in fact occurred, the insurer properly rescinded its acceptance and denied further benefits.
UEF v. Big Sky Petroleum, Montana State Fund, and Melvin J. Strong [4/29/04] 2004 MTWCC 39 Where the claimant informs the insurer that his industrial accident occurred on a date different than the one set out in the accepted claim, and the insurer did not cover the employer on the actual date of injury, the action of the claimant in informing the insurer amounts to a withdrawal of his claim with respect to that insurer and effectively amends the claim to incorporate the correct date. Under such circumstances, the acceptance of the claim is mutually rescinded.

LaPlant v. State Fund [11/24/99] 1999 MTWCC 75 Where State Fund failed to accept or deny a 1987 claim within thirty days, under section 39-71-606, MCA (1985) and Haag v. Montana Schools Group Ins. Authority, 274 Mont. 109, 906 P.2d 693 (1995), it is in the same position as though it had accepted the claim. State Fund is not, however, liable for a wide range of medical bills without proof of a causal relationship to the claimed elbow injury, nor for compensation benefits during all periods of unemployment without proof of disability and causal relationship of disability to the "accepted" claim.

Gunder v. CIGNA [5/3/99] 1999 MTWCC 31 Claimant appealed from the decision of Department of Labor holding that failure of the insurer to deny an occupational disease claim within 30 days does not preclude the insurer from contesting the claim. Claimant asked the WCC to find the "retroactive" application of section 39-71-606(5), MCA (1997) unconstitutional. That section, which specifies that failure to deny within 30 days does not constitute acceptance, was expressly made applicable by the Montana Legislature to matters pending prior to its enactment. The WCC held that application of section 39-71-606(5), MCA (1997) to claims existing prior to the effective date of the statute does not violate the contract clause of either the Montana or United States Constitutions. Given the statement in section 39-72-103, MCA (1995) that rights to compensation for occupational diseases did not vest and could be changed by the legislature, an occupational disease claimant had no contractual right to benefits as described in a particular year's legislation. Given this and in light of applicable precedent, the retroactive application of the 1997 amendment to section 39-71-606(5), MCA was constitutional. (Note: the appeal to the Montana Supreme Court, Gunder v. CIGNA, No. 99-337, was ordered dismissed on May 18, 2000, based upon notice from the parties that the matter had settled.)
Hall v. State Fund [1/13/99] 1999 MTWCC 3 Once claimant's physical condition was accepted as an OD, WCC would not enter debate about whether the diagnosis of the condition was correct. Compensability does not turn on the validity of the diagnosis, but requires only that the claimant suffer an injury or disease of some sort and be disabled as a result.
Wylie v. State Fund [4/3/97] 1997 MTWCC 17 Where section 39-71-606(1), MCA, requires an insurer to accept or deny a claim "within 30 days of receipt of a claim for compensation," it is the insurer's receipt of a claim that triggers the obligation, not the employer's.
Guedesse v. Liberty Mutual Fire Insurance Company [3/12/97] 1997 MTWCC 10 Where the claim form signed by claimant did not state any specific event or any specific time or place for an alleged injury, it fails to identify an industrial accident or injury within the meaning of the Workers' Compensation Act. The "automatic acceptance" rule of Haag v. Montana Schools Group Ins. Authority, 274 Mont. 109, 906 P.2d 693 (1995) comes into play only if the insurer has received a valid claim for injury, containing sufficient information to inform the employer and insurer of the nature and basis of the claim. As the insurer argues, the claim submitted in this case, at best, suggests claimant is suffering from an occupational disease, and the insurer accepted the claim as such.
Estrada v. State Fund [1/14/97] 1997 MTWCC 4 Under Haag v. Montana Schools Group Ins. Authority, 274 Mont. 109, 906 P.2d 693 (1995), the insurer's duty to accept or reject a claim within 30 days arises upon the insurer's receipt of the claim. While section 39-71-601, MCA (1993) allows a claimant to submit a timely claim "to the employer, the insurer, or the department," the insurer does not risk liability under Haag unless if fails to act on a claim it has received.
Smith v. National Union Fire Ins. Co. [10/15/96] 1996 MTWCC 65 A claimant's failure to provide 30 days notice to an employer is a defense to liability. Haag v. Montana Schools Group Ins. Authority, 274 Mont. 109, 906 P.2d 693 (1995) precludes the insurer from raising any defense, including this one, if the claim was not accepted or denied within 30 days as required by section 390-71-606(1), MCA (1991).
Bouldin vs. Liberty Northwest Insurance Corp. [10/8/96] 1996 MTWCC 61 Under the 1995 version of the Occupational Disease Act, in a denied liability case, the DOL, not the WCC, has original jurisdiction to conduct a de novo hearing into whether claimant has an occupational disease. However, the WCC has jurisdiction to determine whether the insurer's initial acceptance of the claim bars subsequent denial. Where the insurer concedes claimant's present condition is the same condition for which she filed the initial claim, the insurer is barred from later denial.
Fox v. Liberty Mutual Fire Ins. Co. [2/1/96]1996 MTWCC 11 Haag v. MSGIA, 274 Mont. 109 (1995), which involves an insurer’s failure to accept or deny liability of an initial claim within thirty days, does not extend to subsequent “demands” made for specific benefits. Insurer’s alleged failure to respond within thirty days to “demand” for specific impairment award does not establish a right “as a matter of law” to that impairment.
Liberty Northwest Ins. Corp. v. Champion International Corp. (Re: Deschamps) [3/27/96] 1996 MTWCC 28 Where insurer clearly and unequivocally accepted liability for claimant’s back condition without reservation of rights, it cannot repudiate that acceptance, but it may seek indemnification from a prior insurer who bears responsibility for claimant’s condition.