Auto Insurance Claims: auto insurance claim adjusters, auto insurance claim, orthopedic doctors

Question
I was in an auto accident 9/29/07.  I was hit from behind and there was $2000 worth of damage on my car.  I was slowing down just below my mailbox and a younhg man hit me and I went about 60 feet.  I have had neck area pain for 3 months.  I couldn't understand why I could no longer do arobics and my daily things like I used to.  I am from P.A. and the have no-fault anhd at fault poli8cies for auto accidents. I woke up Jan. 12th 2008 and was in severe pain with my right shoulder and neck.  I noticed when I would do my exercises at physical therapy I had a hard time lifting my right arm, but I thought that it was due to my neck, and I didn't complain about it to the therapist or the doctor.  My primary care pyhsician never released me. As soon as I woke up on 1/12/2008 and couldn't move my arm, I went to see my PCP.  He sent me to a neurologist who said I might have tendonitist, but I* insisted on an MRI.  I got the MRI and found out that I had a rotocup tear in my right shoulder.  I then called my PCP and he sent me to an orthopedic doctor who said that I should have it repaired, or I am going to have it will only get worse.  She then sent me to an orthopedic surgeon in Pittsburgh who said that if I don't get it done now it wi8ll get worse as I get older.  I called my claims adjuster for my insurance co. and he said O.K. if you have to get it done. I got it done. I came home and did nothing for four weeks. Then my orthopedic surgeon said to start physical therapy- 8weeks.  I am in my 2nd week of this.  Well, last week my primary care physician called and told me that I had been denied the coverage for my surgery and anything after November.  I called my adjuster up and he never sent me a denial letter yet. I stated to call my orthopedic doctors up and they (my insurance co.) never asked my doctors anything as to the reasaon for surgery or if the accident was caused by the surgery.  When I call my insurance co. up, they will not give me any information as to why I was denied.  Isn't my insurance co. supposed to help me?  They are supposed to pay my bills and I have full-tort on my policy.  That's the full coverage benifit in P.A. I have 2 orthopedic doctors saying that it could be a result of the accident. I have been a healthy 52 year old and have no prior accidents ever. I have no medical issues in my medical history other than a water pill for my blood pressure.  I have never had major neck or shoulder problems and until this accident have been quite active.  Now I've sat on this couch more than I ever had in my entire 32 years of marriage.  What is going on with my insurance co.  I have tried to be as honest as I humanly can by giving you all the facts that I know at hand.  Plese give me some solid advice please. Thank-You Cathy

Answer
Hi Cathy,
As I see it, the key to your problem has arisen from the facts surrounding your statement in the question  "I have 2 orthopedic doctors saying that it COULD be a result of the accident."

Since your torn rotator cuff was not discovered until approximately
114 days after the accident, it's damage must be directly connected to the accident by your doctors and medical specialists.  The word
"COULD" from your specialists is not a strong enough connection.

True, your policy requires your insurance company to pay all the medical bills, up to your policy limits, that can be "directly attributed to the accident".  The insurance company is constantly scrutinizing each medical bill to see if it meets those standards.
The weak statement saying that it COULD be a result of the accident is sufficient reason for them to deny the rotator cuff injury.

In my opinion, your next step is to consult with an attorney who has TRIAL EXPERIENCE.  If you don't know one, you can call your county attorney referral service (it's free) and they will refer you to 3-6 qualified attorneys in your area. In many states, the first consultation is free, in others there is a minimal fee of about $20 for the first 30 minute consultation.  You may need to consult with 2 or more attorneys to find one that you are most comfortable with.
A good trial attorney will be able to review your entire claim and offer his/her opinion of the value of your claim and their chances of getting a better narrative report from the surgeon that will definitely place the cause of your torn rotator cuff as a result of the accident.

Since this is a tort liability case, the attorney will usually accept it on a contingency basis, meaning that when they win, they receive a percentage of the settlement.  Should they fail to win, there are no charges.

Having a consultation with an attorney puts no burden on you to retain that persons services, but you will still have a better idea of how to handle your claim.

The statue of limitations in Pennsylvania for settling a personal injury claim is two years.

I hope that you find this information to be helpful.

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Sincerely,
Bennie
San Francisco Bay Area