Results 1 to 5 of 5
  1. #1
    Join Date
    Jun 2016
    Posts
    2

    Default Getting Treatment for an Injury That is Not Covered by Workers Comp

    Me and 3 of my buddies took over a small painting business that we ran over 2 summers. It was just a summer job to help us pay for school and other little things. We had a lot of fun doing it. While working on a house during late summer I fell 2 stories off of a house onto the ground and broke ribs/collarbone/etc. our little business didn't have workers comp because we felt like it wasn't needed. We only worked in the summer, and we made sure we were always safe. So my parents insurance didn't cover any of the bills because they heard from the grapevine that this happened at work. Now, 2 years later I need back surgery, may or may not be from the fall but I can't have it because my insurance won't cover it due to the WC issue. I'm in a disgusting amount of pain and have no idea how to handle this situation. I don't know how much longer I can live with the pain, but there is no way I can pay for this surgery. I would greatly appreciate any tips on how to handle this situation. Thank you.

  2. #2
    Join Date
    Oct 1971
    Posts
    5,048

    Default Re: Small Business Without WC Injury

    Shawnmenden
    my parents insurance didn't cover any of the bills because they heard from the grapevine that this happened at work.
    So what, make em prove it.
    Insurance companies don't have gossip mills and they sure don't base determinations for benefits on rumors - something's missing here.

    What did you tell the doctor?
    Whatever it was, stick to it and demand benefits (unless you told the doctor it happened at work)

    If all fails, apply for Medicaid if you have little or no assets, otherwise sell your yacht and get the surgery.

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

  3. #3
    Join Date
    Feb 2007
    Location
    831 East Morehead St., Ste 355, Charlotte, NC 28202
    Posts
    3,762

    Default Re: Small Business Without WC Injury

    I don't understand why your health insurance won't pay for it. Are they claiming that it is "work related?" If so, what that actually means is that "a workers' comp insurance company may be responsible for paying for it, so it is excluded from coverage under the health insurance policy." The question is not so much "did it happen at work" as it is "Is there another insurance company that should be paying for this injury?" That is what you have to address with the health insurance policy.

    Of course, there was never a workers' comp insurance company involved in your fall at work. Since there is not a workers' comp insurance company involved, the "injury at work" exclusion should not apply.

    Your problem is with your health insurance policy and not with workers' comp.

    Health insurance has to pay unless there is an "exclusion" in the health policy that specifically excludes your situation. Get the policy itself and read the exclusions, so that you can deal with it intelligently. It should say that it does not pay for injuries that are "covered by workers' compensation insurance" and not say that it does not pay for "work-related injuries." Many work-related injuries are not covered by work comp for various reasons, and all those non-covered injuries should be covered by health insurance policies.
    Last edited by complwyr; 06-27-2016 at 05:22 PM.
    The North Carolina Court of Appeals has held that "In contested Workers' Compensation cases today, access to competent legal counsel is a virtual necessity." Church v. Baxter Travenol Labs, Inc., and American Motorists Insurance Company, 104 N.C. App. 411, 416 (1991).

    Bob Bollinger, Attorney and Board Certified Specialist in NC Workers' Compensation Law

  4. #4
    Join Date
    Jun 2016
    Posts
    2

    Default Re: Small Business Without WC Injury

    Quote Quoting tony View Post
    Shawnmenden So what, make em prove it.
    Insurance companies don't have gossip mills and they sure don't base determinations for benefits on rumors - something's missing here.

    What did you tell the doctor?
    Whatever it was, stick to it and demand benefits (unless you told the doctor it happened at work)

    If all fails, apply for Medicaid if you have little or no assets, otherwise sell your yacht and get the surgery.

    Tony

    Well i had to go to the hospital that day by ambulance in my painting clothes. I don't think i explicitly said i was at work, but my co workers or friends could have easily told a doctor.

    So i don't know how that impacts it.

  5. #5
    Join Date
    Oct 1971
    Posts
    5,048

    Default Re: Small Business Without WC Injury

    Shawnmenden
    Quote Quoting Shawnmenden View Post
    Well i had to go to the hospital that day by ambulance in my painting clothes. I don't think i explicitly said i was at work, but my co workers or friends could have easily told a doctor.

    So i don't know how that impacts it.
    All private Health insurance policies have language that exclude work related injuries - self employed or otherwise.
    They put that language in those policies for a reason, I'm positive it will hold up in a court of law - you agreed to those terms when you bought the policy.

    In order to receive benefits, someone had to file a claim.
    The typical claim form has several questions - one of them being the reason for the condition or injury - is it work or accident related?
    You had to tell the doctor something - I know he asked you how you got hurt - whatever you told him, stick to it.

    Did you or the hospital submit the claim to the carrier?
    If the hospital did, they must've said it was work related - somehow they came to that conclusion.
    Concealing or misrepresenting facts to obtain benefits can be interpreted as fraud, be careful how you handle this, don't lie.

    Depending on the facts of your case, you may be better off admitting it was work related - they may still be obligated to pay.
    Consult a lawyer before you dig this hole any further, don't take any action until you find out where you stand legally.
    You may have serious problems, be careful.

    Tony
    Moderator Responses are based on my personal bias, experience and research - They do not represent the views of the admin nor may be accepted in the legal community, always consult an attorney.

Similar Threads

  1. Workmans Comp Injury Covered Under FMLA
    By IVPush33 in forum Employment
    Replies: 1
    Last Post: 07-31-2013, 12:24 PM
  2. Replies: 1
    Last Post: 12-13-2012, 06:56 AM
  3. Replies: 1
    Last Post: 11-04-2011, 10:09 AM
  4. Replies: 2
    Last Post: 10-02-2010, 03:15 PM
  5. Will A Recurrence Of Injury Be Covered By Comp
    By worried in forum Insurance Company Practices
    Replies: 1
    Last Post: 04-23-2006, 06:35 PM

Bookmarks

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
 


Find a Lawyer