Insurers: Adjusters

Thompson v. Montana State Fund [08/30/13] 2013 MTWCC 25 Where a case involved a complex factual situation implicating multiple, overlapping medical conditions and with contradicting medical opinions, it was not unreasonable for Respondent to discontinue TTD benefits after it determined Petitioner was at MMI for both her orthopedic condition and her vocal cord injury and after receiving physician-approved alternative job analyses. Whether Petitioner could in fact perform the duties of the positions constituted a legitimate factual dispute which is a reasonable basis for an insurer to deny a claim.

Dauenhauer v. Montana State Fund [07/03/12] 2012 MTWCC 22 The claims examiner was informed that one of the reasons Petitioner needed to see a physician was because the statute of repose was about to run under § 39-71-704(1)(e), MCA.  The claims examiner interpreted this as a desire to keep the 60-month time limit from running without a need for medical care and denied the request.  The denial was not unreasonable, even though Petitioner was primarily seeking follow-up care due to numbness in his extremities resulting from his neck injury.

Brown v. Hartford Ins. Co. [12/16/09] 2009 MTWCC 38 The Court found the actions of two claims adjusters to be unreasonable in adjusting Petitioner’s claim where: the first adjuster noted after reviewing medical records that Petitioner’s condition was not work-related when the medical notes explicitly stated that it was; the file sat for four months with no adjuster assigned to it; the second adjuster sat on the file for seven months without seeking clarification regarding her “confusion” about the diagnoses; and the second adjuster continued to deny liability and again failed to seek clarification after the physician again examined Petitioner and found her to be suffering from an occupational disease.

Kramer v. Montana Contractor Compensation Fund [10/27/08] 2008 MTWCC 48 The Court was troubled by some actions of the claims adjuster, including communications with the treating physician which, while ostensibly for the purpose of clarifying Petitioner’s physical restrictions, were also apparently intended to call Petitioner’s credibility into question with his treating physician. This behavior is inappropriate and is not consistent with reasonable claims handling.
Hernandez v. ACE USA [4/24/03] 2003 MTWCC 32 By giving its insured veto power over settlements, the insurer violated section 39-71-107(3), MCA (2001), which requires appointment of a resident adjuster with settlement authority.
Hernandez v. ACE USA [4/24/03] 2003 MTWCC 32 Under section 39-71-107(3), MCA (2001), insurers providing workers' compensation coverage in Montana must appoint a resident Montana claims adjuster and give that adjuster final settlement authority with respect to Montana workers' compensation claims.
Patrick v. State Compensation Insurance Fund [4/4/00] 2000 MTWCC 20 Penalty under 39-71-2907, MCA (1997) awarded where adjuster unreasonably limited rehabilitation evaluation to the gathering of information to support her prior conclusion claimant suffered no wage loss. Facts suggesting unreasonable delay and denial of rehab benefits included adjuster's hiring of private investigator based only a computer generated "fraud flag," which in turn was based only on claimant's failure to return to work within a predicted period of time, and did not consider claimant's serious preexisting condition upon which work injury was imposed; adjuster's apparent communication to investigator, without any support, that there was no objective evidence of injury and treating physician was "making matters worse"; referral for neuropsychological evaluation without basis; provision of report unfavorable to claimant, but not report favorable to claimant, to expert; and general tendency to ignore evidence favorable to claimant while seeking opinions to support adjuster's conclusion. Note: After decision, the parties settled and presented a Stipulated Judgment to the Court, which then issued its Order Nunc Pro Tunc For Entry of Judgement and Dismissal with Prejudice, Patrick v. State Comp. Ins. Fund, 2000 MTWCC 20A.