QuestionI was rear ended in an auto accident and had back and neck pain. Had a cat scan done of the head and they found "something." Had an MRI done on the brain and found a pituitary tumor.
I was not aware of the tumor before the accident - my question. Does the auto insurance company have to pay for part or all of the costs pertaining to the diagnosis and treatment of the tumor?
Answer
Overview tort law personal injury legal claims
Reasonable and necessary medical costs
Head trauma
"Light up" preexisting condition
Asymptomatic condition made worse
Effective communication with insurance claims adjusters
Dear Bill,
That must have been a shocking piece of news for you. These are treatable, so best wishes. I hope that your tumor will respond to treatment and is not going to be any long term problem for you.
General rules of tort law. The one who caused the accident is known as the tortfeasor. Your cause of action is versus him, NOT his insurance company, although it is the company that will decide what to pay and what to fight over.
I am going to make a general observation, followed by specific comments on your case. This is serious and a bit complex, so I will put in some extra time for you; and I have done some medical research I will pass along to you. It is impossible to speculate in your case since I do not have any idea of the kind of trauma your brain suffered, nor any information at all about the tumor. But I will just go with what you did present to me.
In general, the tortfeasor is going to be responsible for ALL the medical costs that meet all three prongs of this test:
1. The medical cost must relate to a condition that was CAUSED by---or MADE WORSE by---the trauma of the accident.
2. The expense must be necessary to diagnose (or to treat) a condition or to investigate a symptom caused by the trauma of the accident.
3. The amount of the expense must be reasonable.
The places that the insurance company will attack your request to pay for the diagnosis and treatment of your tumor are numbers 1&2 above. They will contend that the trauma had nothing to do with the formation of the tumor. Also, they will contend that the symptoms which caused your doctor to order the CT scan were not at all caused by or related to the trauma of the accident.
So, your chances of getting any money for either or both the diagnostic tests and the treatment will depend SOLELY upon the strength of your doctor's reports in tying the trauma to one of three POSITIVE statements:
1. BEST—he says that the trauma caused your tumor (not likely). In that case you have a HUGE CASE, and you get money for diagnostic costs, treatment costs, and a huge general damage award. Best to see an attorney if this is the report of your doctor.
2. PRETTY GOOD—he says that your tumor was preexisting, but slow growing and you never would have noticed it for many years, but the trauma lit up something about it (that caused symptoms that he investigated), and as a consequence it has become active and growing and you will need treatment. This is what we might call a "light up" of a previously asymptomatic (i.e. showing NO symptoms) condition. . In that case you have a BIG CASE, and you get money for diagnostic costs, treatment costs, and a PRETTY BIG general damage award. Best to see an attorney if this is the report of your doctor.
3. MORE LIKELY—he says that the trauma had nothing to do with the tumor. But you DID have symptoms from your trauma that caused him to order the CT scan. In that case, you would get money for the CT scan. He could tell from the scan that the tumor was not related to trauma, so the costs of the MRI would be up for debate. You would get no money for general damages related to the tumor, nor would the tortfeasor have to pay for your treatment.
Gently and humbly "EDUCATE" YOUR DOCTOR. I will bet you a hundred bucks that your doctor never even mentioned your head trauma as a potential factor in lighting up your tumor. He DOES NOT WANT TO GO OUT ON A LIMB FOR YOU. So he plays it safe. It is UP TO YOU TO PUSH him to consider the effect of head trauma in this case. Hopefully you can show how you DID have direct head trauma on the back head rest or if your head struck the side window somehow. Try to recall and be sure to bring to his attention if one of these did occur inasmuch as it could be critical to whether or not you get money for the medicals and any general damages.
BUT, be aware that your doctor has a HUGE EGO, especially when it comes to hearing anything regarding his professional opinion from a mere patient. So you will have to tread lightly on this in order for him to entertain any thought whatsoever that head trauma had anything whatsoever to do with symptoms from your tumor.
Do a lot of your own research on the possibility of a head trauma causing a "light up" or renewal of a preexisting tumor. Here is some general information, with a couple of trauma references discovered.
NEW TOPIC: some sites for tumor information, especially as related to trauma:
Basic information on pituitary, no mention of trauma:
http://health.allrefer.com/health/pituitary-tumor-info.html
Basic information on pituitary, no mention of trauma:
http://64.233.161.104/search?q=cache:569lxmeXiKoJ:ymghealthinfo.org/content.asp%...
Basic information on pituitary, with mention of brain trauma:
http://64.233.161.104/search?q=cache:gWI68pLCiY8J:www.nlm.nih.gov/medlineplus/en...
More basic information, with mention of Hypothyroidism and trauma:
http://64.233.161.104/search?q=cache:8yIcM9mDgiwJ:members.aol.com/henryhbk/endoc...
More basic information, with mention of Hypothyroidism and trauma:
"Loss of pituitary function due to direct compression from a tumor or radiation therapy typically occurs in steps. Production of one hormone after another is lost until finally corticotropic function is lost as well. This graded loss of function relates to the sensitivity of pituitary cells to EXTERNAL TRAUMA."
http://64.233.161.104/search?q=cache:Tsd9i_K2dv0J:hopkinsneuro.org/disease_and_c...
TRAUMA can "light up" a previously slow-growing tumor;
Untreated patients with hypopituitarism can survive for many years with their disease. Survival of untreated patients will depend to a large degree on the severity of the hormonal deficit, the axis involved, the etiology of the hypopituitarism, and other concurrent illnesses. Untreated patients with hypopituitarism have increased morbidity and mortality. Such patients may remain compensated until some stress, TRAUMA, prolonged cold exposure, infection or medications precipitate an acute
life-threatening decompensation.
http://erc.endocrinology-journals.org/cgi/reprint/8/4/287.pdf#search=%22trauma%2...
Loss of normal pituitary function has been reported after major head TRAUMA:
http://www.endocrinolog.com/pituitary.html
New Approaches to Managing Tumors of the Pituitary Gland Offer Patients Hope
Understanding the pituitary tumor as being SLOW-GROWING (i.e. you never would have noticed it in the absence of head trauma?)
Tumors of the pituitary gland are generally slow-growing benign adenomas that are classified as either functional (60%), meaning that they hypersecrete one or more hormones, or nonfunctional (40%), meaning that they secrete no hormones but instead are just masses of cells. These tumor masses can compress the pituitary gland itself, which can cause hormone deficiency, or adjacent structures such as the optic nerve, which can lead to disturbances in and loss of vision. http://www2.mdanderson.org/depts/oncolog/articles/04/9-sep/9-04-1.html
SUMMARY REGARDING YOUR QUESTION:
In the best possible answer to your question, if you can get your doctor to state that the trauma from the accident lit up the tumor or made it active from an inactive state, then you get all three: 1) payment for diagnostic tests; 2) payment for treatment; and 3) a big general damages award.
In a more likely direct answer to your question, because the tortfeasor is likely not going to be responsible for treatment of the tumor (and general damages) unless your doctor can say that it became active or grew as a result of the trauma, you will have a more modest award for diagnostic costs. Since tumor light up is not likely going to be his diagnosis or etiology (that means the cause of the tumor), we can conclude that treatment of the tumor itself is probably not going to be the responsibility of the tortfeasor.
But even if the tortfeasor is not going to be responsible for treatment, it IS POSSIBLE to hold his insurance company to pay for the diagnostic testing IF CERTAIN CONDITIONS ARE MET.
Thus, as to the costs of doing the CT and the MRI, that could be a different story. The question is: why did your doctor order a CT scan to begin with? Was it because of pain associated with the trauma? Can he say that pains from the trauma (even if not associated with the tumor) necessitated the further investigation via the CT? Then, the tortfeasor should pay for the tests. Much better if he could say that the accident trauma caused a preexisting condition to become symptomatic and thus the CT and MRI were necessary. Then the tortfeasor should pay for the tests, the treatment, and your general damages.
BUT, If your doctor cannot give either of those causal connections between the trauma and your condition, then expect that the insurance company WILL fight having to pay for these diagnostic tests on the basis that you had a condition that was in no way caused or lit up by the trauma from the accident.
I am going to add one little wrinkle here, and it is a fine point, but one that you might wish to make. This is just a little additional thought on the "light up" scenario, since I believe that is your best hope. Let’s say that you had the tumor prior to the accident, which is likely the case. But let's also say that it was dormant and not likely to cause you to notice any symptoms whatsoever in the coming years. Thus, your doctor would say that absent this accident, you could have continued on your way for many years without ever noticing the tumor, and it would not have caused you any problem whatsoever.
BUT (and this is your best chance, I think), if you can just get your doctor to say that the trauma lit up a previously asymptomatic condition, then you will get all that you are seeking. Work at it and especially the research end by which you can GENTLY and RESPECTFULLY INVITE his attention (never use "I DIRECT your attention to…"; instead, say, "May I respectfully invite your attention to …")
FINAL TOPIC: Effective communication with insurance claims adjusters. Establish Firm, Professional, and Positive Relationships With the Insurance Injury Claims Adjuster http://www.settlementcentral.com/page0059.htm
Always communicate with the adjuster in writing, showing your own analysis of value. It is OK I guess to have one call or so, but no more. Always have your information and ammunition in writing to give to the adjuster.
Let him know that you are FIRM IN YOUR RESOLVE to get what you are demanding (NOT "asking", since that invites a counter-offer, but instead "demanding" as fair and reasonable compensation) by asking him what the options are to resolve the matter fairly should he not agree to a reasonable claim value. In other words, let him know that you will go through with a court filing if need be.
Remember these tips, do your homework, print out your evidence, show resolve to get your fair settlement, and you will DO JUST FINE.
I trust that my extra time here has produced some information that has been of value to you, and thus I would respectfully request that you take the time to locate the feedback form on this site and leave some feedback for me.
Best Wishes,
Dr. Settlement, J.D. (Juris Doctor)
http://www.SettlementCentral.Com
