Secondary insurance questioning fall in a nursing home?

by Dirk
(Mercer Island, Washington, USA)

My mother was in a nursing home for weakness and a hamstring tear. She fell while being helped by an aid to go to the bathroom during the night. They were supposed to be using 2 people according to her care plan, but were only using one.

She broke her hip in the fall, and surgery was done the next day. She spent 4 days in the hospital. We changed to a different nursing home after leaving the hospital.

Now our secondary insurance (primary is Medicare) is contacting us about the accident, wanting to know if it occurred on commercial property. We never filed a complaint. Should we respond to them? Should we contact an attorney? Will they not pay the hospital bills if we respond? The accident was two months ago. Thank you.

Visitor Question:
Disclaimer: Information provided in our response is NOT formal legal advice. It is generic legal information based on the very limited information provided. Under no circumstances should the information in our response, or anywhere else on this site be relied upon when deciding the proper course of a legal matter. Our response does NOT create an attorney-client relationship. Always get a formal case review from a licensed attorney in your area.

ANSWER for "Secondary insurance questioning fall in a nursing home?":

Dirk (Mercer Island, Washington, USA):

Cooperating with your insurance company is likely a requirement under your insurance policy. Failure to do so may result in denial of coverage. When considering payment to an insured, a secondary insurance company has a right and an obligation to investigate the circumstances of the injury. Without a thorough investigation, the insurance company will not have a legitimate basis upon which to pay the claim.

While reading your insurance policy can be tedious, under these circumstances, it's a good idea for you to do so. That way you will have a better understanding of your rights and duties under the policy, and those of the insurance company.

Don't panic. At this point there isn't any reason to contact an attorney. If, for any reason, the insurance company later denies the claim, then you can consider retaining an attorney. For now, cooperate and let the insurance process run it's course.

The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from an attorney licensed in your state. Find a local attorney to give you a free case review here, or call (888) 647-2490.

Best of luck,

Judge Calisi

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