Uninsured Employers' Fund: Reasonableness of Claims Handling

Dostal v. Uninsured Employers' Fund [12/04/12] 2012 MTWCC 45 The Court found that the UEF unreasonably delayed and denied a treatment referral where Petitioner’s treating physician repeatedly requested the referral and the UEF refused to authorize it solely because it would have required Petitioner to travel to Billings, when the UEF had previously authorized Petitioner to travel to Billings to be seen by this provider and the provider had performed three surgeries on Petitioner in Billings.

Dostal v. Uninsured Employers' Fund [12/04/12] 2012 MTWCC 45 The Court found the UEF’s conduct unreasonable where it ignored several referral requests from Petitioner’s treating physician.   Although the UEF was aware of the requests, the requests went unheeded because the treating physician did not know that the UEF would not consider requests contained within treatment notes but would only consider referrals if they were submitted on a “form” which the UEF had never created.

Dostal v. Uninsured Employers' Fund [11/05/12] 2012 MTWCC 41 The Court concluded the UEF unreasonably denied reimbursing Petitioner for travel expenses where the only justification the UEF offered until this Court denied the UEF summary judgment on the issue was an interpretation of case law which the Court found unreasonable.  While an insurer may have more than one basis for a denial and is not necessarily expected to set forth every potential justification for denial at the time it denies a claim, in the present case, the only apparent reason for the UEF’s denial of the travel reimbursement was the UEF’s reliance on an incorrect version of the WCA.   Applying the wrong year of the WCA is not a reasonable error, and subsequently searching for alternate justifications for the denial does not erase the unreasonableness of the UEF’s denial.

Dostal v. Uninsured Employers' Fund [11/05/12] 2012 MTWCC 40 The UEF unreasonably refused to pay Petitioner’s impairment award where the UEF’s argument was, essentially, that although no justifiable reason existed at the time of its refusal to pay Petitioner’s impairment award, future events could provide it with a justifiable reason for refusing to pay.

Dostal v. Uninsured Employers' Fund [02/16/12] 2012 MTWCC 5 The Court concluded that the UEF was unreasonable in handling a claim where it withheld the payment of an impairment award which was due in 2002 and later alleged that it was justified in withholding this payment after it suspected it had overpaid the claimant’s TTD benefits over seven years later.

Dostal v. Uninsured Employers' Fund [02/16/12] 2012 MTWCC 5 The Court concluded that although the UEF reasonably terminated a claimant’s TTD benefits after it had evidence that the claimant had returned to work, the UEF acted unreasonably  when it failed to respond to or investigate the claimant’s counsel’s subsequent correspondence in which she alleged that the claimant had not returned to work and that the UEF had terminated the claimant’s benefits in error.