Insurance Refusing to Pay for Surgery...

by Nicole
(Texas)

I was injured in a slip and fall accident at a local fast food chain. The insurance company accepted fault. They have paid for some of the medical bills, but now say that they have exhausted what they can pay for until we settle.

I am 10 months into this injury, and the doctor says I have a possible torn medial meniscus in my right knee. I have already done two rounds of physical therapy, and now the doctor wants to do arthroscopic surgery. I am unable to pay the out of pocket expenses for this surgery, and the insurance company claims they are not able to help. They claim they have paid as much as possible prior to settling my claim.

What should I do? Please help.

Disclaimer: Information provided in your response is not formal legal advice, it is generic legal information and is based on the very limited information given in your question. You should always get a formal case evaluation from a licensed attorney.

ANSWER for "Insurance Refusing to Pay for Surgery...":

Nicole:

As you well know dealing with an insurance company can be a daunting task. It is good to know in your case the insurance company accepted liability.

The problem you are running into is a common one, especially for those who are not represented by Attorneys. There are Personal Injury Attorneys in your area who, over years of practice, have developed professional relationships with physicians, chiropractors, and other persons who may be involved in a victim’s recovery. Those relationships include something called “Letters of Protection,” or “LOP”s.

An LOP is a written agreement between an Attorney and a Medical Provider. The agreement states that the Attorney is providing legal representation to the Medical Provider’s patient. It then goes on to say that the Attorney agrees to act as a fiduciary, or Trustee for the settlement funds her client is expecting at the end of the lawsuit, or in a negotiated claim.

The Agreement also says that if the Medical Provider will hold back the medical bills until the end of the case the Attorney will guarantee she will pay the Medical Provider before any settlement funds are paid to the patient/client.

Doing so does not mean the Attorney cares more about the Medical Providers than she does about her own client. The manner in which these cases work is that even if there is no Attorney involved, when a victim receives a settlement she is supposed to pay the Medical Providers first anyway.

The problem with that, as you have seen, is that without LOPs from Attorneys the Medical Providers will not hold back the bills. They are afraid if the victim receives the settlement funds she may “run off” with it without paying her medical bills. It happens all the time.

You may be thinking you can then go ahead and draft an LOP for your Medical Providers. You can certainly draft one but the Medical Providers, in almost all cases, will not accept it from you.

With that understanding you will have to consider your options. Contacting a skilled Personal Injury Attorney would be a good start. Most Personal Injury Attorneys do not charge any legal fee for an initial office consultation. That might be your best option.

Since laws change frequently and across jurisdictions you should get a personalized case evaluation from an attorney licensed in your state (if you haven't already). Find an experienced local attorney to give you a FREE personalized case review here.

Best of luck,

Law Guy

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