First Comp-Appellate case on a battle between insurers

The Colorado Court of Appeals issued a decision today involving a dispute between two insurers. The claimant was injured and in the case there were two employers. The direct employer had Pinnacol Assurance and the statutory employer had First Comp as its workers comp insurer. Pinnacol alleged it had cancelled the policy so the direct employer had no coverage leaving the statutory employer and its insurer to be responsible in the case. There was evidence presented and the hearing judge ruled that First Comp was the insurer in this case. First Comp, appealed and the Court concluded it had no standing to appeal the cancellation determination. In effect the cancellation statute was between the direct employer and Pinnacol and the injured worker but not with First Comp. It sounds to me a bit like the legal concept of privity. Even though First Comp takes a direct hit when the direct insurer is able to walk away because it cancelled the policy the lack of a close statutory relationship or benefit then prevents First Comp from appealing the issue. It lacks standing said the court so First Comp's appeal was dismissed. Certainly here the legal concept of standing to appeal was raised to prevent issues remote from the claimant from interfering with the compensation process. Perhaps an insurer would not pay benefits pending an appeal which can take over a year to the harm of the claimant or his dependents (in this case the injured worker had died). Imagine waiting for benefits while two insurers battled it out!

All About Claims Newsletter March 2011

The Colorado Division of Workers Compensation has just released a new newsletter. In it you can read the comments of former Judge Jaynes who recently passed away. There is also something on the DIME (Division Independent Medical Exam) process. The newsletter approach is a good one and would be even better if it were a regular feature. Giving us a glimpse inside the state agency makes it rather unique. Being able to just talk about things in a very informal way is helpful. It puts a face on what we sometimes see as bureaucratic when actually it is human. Many good people do their best in this field. The field itself may need much improvement but those who work in it have not been the problem. In fact looking back on the many years I have been doing it I have to acknowledge that the people at the Division and those handling hearings have been, for the most part, very decent and intelligent people. They are decent because they are respectful of others even when they must follow the rules. They are intelligent in doing their best to be fair and legally accurate in what is often a very complex field. Most of them and most who practice in this area believe they are making a difference as do I. Having said that I should add that some adjusters and employers do not play fair at all. Yet dealing with them can be difficult but also very rewarding when done right.

Colorado Injured Workers Survey

Over at the Colorado Division of Workers Compensation they just posted the results of a survey now required by law. Once the case is over or close to over a survey request is sent out to the claimant. For this first survey not that many responded but it is enough to tell us something. The survey itself asks about courtesy, promptness, medical care and overall satisfaction. The weakest area, according to claimants finishing their case, is in disputes being promptly resolved. Amen to that as delays are common in a field originally set up with good intentions. Most cases seem to take 2 years if they involve a serious injury and an attorney. Some cases go much faster but often it is because they are being treated as minor. I have always planned on at least a year but it does depend on the injury and how much medical care is needed. Even then many cases seem to drag on largely because the system has remedies that take time to work through. A Division IME adds a minimum of 3 or 4 months to the process. You file this paper and wait for the other side. Then they file and you respond. Then you wait for the Division to give you doctor names and then once selected there is a window within which you must set the appointment. Even then it takes time to receive the report and more time for the insurer to act before the claimant can act. It is a bit like a baseball game as the law gives each side a time at bat so no matter how fast you want to go it takes time to line it all up. As for the survey results you can access them by clicking here. Pinnacol received a 3.6 grade out of 5 for overall satisfation. Zurich Insurance was a 4 and the worst among the larger companies was Kroger at 2.5 but all the results have been posted. You may need a spreadsheet program to look at it all but what it tells me is that the overall grade is like a C or C plus. Let me add this...it is not good enough for those disabled and relying on a government mandated compensation program to say it was just okay. Claimants are often hurting physically, financially and are also stressed by the situation even under the best of circumstances. They deserve courtesy, promptness and decent medical care. To me the lower the grade the more adversarial the company. Persistent low grades on surveys may warrant further review or further regulation.

Social Security Compassionate Allowances

Those seeking Social Security Disability often have to go through a long and tedious process. You file, get evaluated which takes weeks if not months and very often are then denied. In Colorado you can then appeal and seek a hearing. However any hearing date is delayed for many months. I have been figuring on it taking a year or longer for the hearing and decision. Even when you win the matter must be processed for you to begin receiving benefits. If I had to estimate the time from beginning to end I would have to say the process will take over 1 1/2 years. Typically from the time you start to the receiving of benefits is long but I say that if you can no longer work get the ball rolling on this. Doing nothing is foolish as there may be things you or your attorney can do to get ready. But there are exceptions to all this. Sometimes people are granted benefits right off the bat. Most of us are not that lucky. Despite any delay if you obtain benefits you may get them backdated to a point 6 months from when your total disability actually started. That is the rule for everyone and the date of disability or onset is not always easy to figure out. Often the judge will do so in his decision. Anyway the point of this blog posting is to make you aware that the agency does have a fast track in certain cases. It is called Compassionate Allowances. For example if the person has early onset Alzheimer's disease they can be fast tracked. In other words certain serious problems can be expedited so benefits flow faster. There are at present some 88 diseases and conditions but this list can get expanded from time to time.

The Zolman Case on Bad Faith

The Colorado Court of Appeals just issued the Zolman decision on March 3, 2011 that concerns a civil claim for bad faith against Pinnacol. In this case which arose out of a workers comp case the claimant was upset with Pinnacol denying treatment and denying a change of physicians. A separate lawsuit was started alleging bad faith. This can mean a trial by jury on whether Pinnacol acted in bad faith which involves acting unreasonably. Pinnacol filed a motion for summary judgment against the civil case which was granted. This was affirmed by the Court of Appeals. So the claimant or rather the plaintiff in the bad faith case lost the case. Summary Judgment is a severe action and historically is not granted if there are questions of fact that should go to a jury. In Zolman there certainly were questions of fact on what is appropriate treatment so you would think the issue of how reasonable Pinnacol was should go to a jury. That is Pinnacol had what it believed were good reasons for denying and the claimant had reasons for saying it was unreasonable. It was a battle of medical experts which is common in this area. Yet the Court decided Pinnacol acted reasonably as a matter of law. Certainly when there are no genuine issues then a summary judgment is appropriate and that is what the case says. What I find puzzling is the use of the concept of "fairly debatable" apparently as a basis for concluding Pinnacol acted reasonably as a matter of law. As I understand it they are saying that the need for treatment was fairly debatable given doctors did side with Pinnacol but to me if there are doctors going the other way even if the dispute could be reasonable you still could go to a jury. On November 10, 2010 another panel of the Court of Appeals in Sanderson did decide that fair debatability alone does not defeat a bad faith claim. You have to wonder if these two cases are reconciliable on the basis to grant or deny summary judgment. In any event Zolman does have the Court deciding that Pinnacol's actions did not rise to the level of bad faith.

Pinnacol Has 3 New Board Members

The Denver Business Journal is reporting that 3 new people were voted onto the Pinnacol board by the legislature. One of them was highly critical of Pinnacol so it will be interesting to see what comes of this. Pinnacol Assurance is Colorado's largest workers comp insurer and has a long history. It was originally set up by the state and is a hybrid of public and private interests. Pinnacol wants more autonomy and yet many in the state legislature are upset with how it now operates. See for example one recent legislative effort in an article in the Denver Post. However Pinnacol does have points going for it. I have previously reported on this so this is just another entry in an ongoing story.
UPDATE: New Board votes to take away the CEO's bonus and in this article in the Denver Post more is discussed about Pinnacol.