This is a review of a workers compensation coverage claim which was unable to be negotiated at the administrative level and which ultimately found itself in a state district court.
The dispute in this case involved a subcontractor who had been injured in a company vehicle. The subcontractor disagreed with the insurance company’s doctors over his level of disability, and filed an appeal to state district court where he presented the written testimony of two independent doctors supporting his contention.
Statement of Facts…
Arthur Ralko was initially hired by Ardshaw Taxi Company on January 12th, 2011. Ralko, like many other cab drivers, worked by leasing a vehicle from the taxi company, and he was officially described as a “contractor – subcontractor” to Ardshaw. Ralko paid $150 a day to the taxi company for which he received use of a cab for 24 hours. The taxi company would dispatch pickups to him via radio, and any money he made would go directly to him.
On February 14th, 2011, while on his way to pick up a fare, Ralko was driving when suddenly he was unable to control the cab. His cab veered sharply to the right and collided into a curb.
The collision with the curb caused the airbags to deploy and Ralko’s face was pushed directly into the front airbag. The force of the collision moved Ralko’s legs forward and into the bottom of the cab’s dashboard. Although stunned, Ralko remained conscious after the accident. Another driver stopped and spoke with Ralko. Ralko said he was in pain and asked the driver to call 911.
Within minutes the police and paramedics arrived. They stabilized Ralko and transported him to the local hospital’s emergency room. There he was treated for his injuries. The doctors ordered both an MRI and a CAT scan. The result of the examinations revealed Ralko suffered a herniation to his disk at the C4 level. The results also revealed Ralko suffered a break to the tibia and fibula in his right leg.
Ralko filed a workers compensation coverage claim with the taxi company’s insurance carrier. The insurance company assigned two orthopedic surgeons to examine Ralko to determine the extent of his injuries. The first doctor concluded Ralko’s injuries, although painful, were not debilitating. She said with approximately 30 days of rehabilitation Ralko should be able to return to his normal work activities.
Ralko thoroughly disagreed with the insurance company’s doctor’s assessment, and he asked to be examined by a second orthopedic surgeon. The insurance company provided him with a new orthopedic surgeon who also performed a series of tests. The second doctor’s diagnosis and prognosis was similar to the first. The results of the examination were relayed to the insurance company.
Based upon the doctors’ findings, the workers comp insurance company only agreed to award Ralko an amount of workers compensation coverage sufficient to pay his medical bills and lost wages for the 30 day period he was unable to work.
Ralko disagreed with both the insurance company’s doctors’ diagnoses and prognoses. He decided to hire his own doctors to evaluate his condition. Those two doctors ordered additional examinations. Those examinations included an additional MRI and CAT scan. After reading the results of the examinations, Ralko’s own doctors diagnosed his injuries as:
“…serious sprain to the tendons and ligaments of Ralko’s right knee, disk herniation to his disk at the C4 level and a broken tibia and fibula to his right leg.”
His doctors also stated Ralko’s injuries constituted partial to full disability, but could not confirm such disability until at least 90 days after their initial diagnosis.
Ralko brought this new information to the insurance company and requested a more substantial settlement. The company refused, stating that the findings of their own doctors were accurate, and Ralko should be able to return to work in 90 days. Ralko responded by filing a petition in state district court.
The insurance company, adamant that Ralko was exaggerating his injuries, filed a Motion for Summary Judgment with the district court. Their motion contended the claimant did not have a meritorious claim, nor did he present any material facts or issues of law which might have support his claim that he should receive more workers compensation coverage.
The Hearing on the Motion…
At the hearing on the Motion for Summary Judgment, the workers compensation insurance company entered into evidence the diagnoses and prognoses of the doctors who they assigned to evaluate Ralko. They also called the doctors to testify in support of their findings.
Although heavily cross-examined, each doctor was able to thoroughly defend their findings. They went through the medical charts of Ralko from the time of his admittance into the hospital through their final examinations of him. Both were undaunted in their conviction that Ralko could resume work after 90 days from the date of their initial examinations. When the insurance company’s attorneys completed their presentation of their case they rested.
Ralko’s attorneys then began the presentation of their case. They presented the doctors’ diagnoses and prognoses of Ralko. Although Ralko requested their appearance the doctors refused to testify on Ralko’s behalf. All Ralko’s attorneys were able to present were the written diagnoses and prognoses of Ralko’s injuries.
Ralko’s attorneys also called him to the witness stand. He made his way to the stand using crutches. When examined by his attorneys, Ralko testified his injuries were so severe as to limit his abilities to walk, sleep, and work. He said as a result of the injuries he also suffered from loss of consortium.
Once Ralko’s attorneys finished examining him, the insurance company’s attorneys began their cross-examination. During their cross examination, they were able to illicit from Ralko an admission that he only used his crutches on the day of the hearing.
They were also able to illicit an admission Ralko consulted with 4 other doctors before he found the two whose testimony he presented. The four other doctors did not find Ralko’s injures to be serious enough to merit full disability. Ralko admitted on the stand that he had been “doctor shopping.”
With that both sides rested and closed their cases.
After reviewing the admitted evidence and testimony of the witnesses the court made the following decision.
“This workers compensation coverage case has come before us as a result of the inability of the claimant/plaintiff and the insurance company to come to an agreement regarding the injuries the claimant suffered and the resulting medical bills and degree of disability suffered by the claimant. As a result of the disagreement, claimant filed his case in this court.
The defendant filed their Motion for Summary Judgment. In the motion the defendant claimed the claimant/petitioner’s evidence did not support his claim for damages. The defendant states the claimant/plaintiff’s case failed to provide material facts or issues of law sufficient to survive a Motion for Summary Judgment.
The court reviewed the evidence presented by the claimant. After so doing, we find the evidence presented by the claimant/plaintiff to be lacking in material facts or law sufficient to survive the defendant’s Motion for Summary Judgment. We therefore find for the defendant and grant their Motion.”
- Workers compensation coverage is normally available to full-time employees. That insurance can also be made available to subcontractors. In this case the cab driver only leased a vehicle from the taxi company but the coverage extended to subcontractors as well as full-time employees.
- Workers compensation coverage insurance claims can be escalated from the insurance administrative process to the courts when there is a bona-fide contention over the facts of a workers compensation claim.
*This case example is for educational purposes only. It is based on actual events although names have been changed to protect those involved. Any resemblance to real persons or entities is purely coincidental.
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