Court Rules That Insurers Must Weigh Independent Medical Experts’ Opinions Against Conflicting Evidence
The South Dakota Supreme Court has reversed a circuit court’s dismissal of a worker’s lawsuit claiming Dakota Truck Underwriters and Risk Administration Services denied him workers’ compensation benefits in bad faith. The opinion, filed on September 28, 2016, concluded that an insurer cannot assume the truthfulness of a consulting medical expert’s report when deciding whether to deny coverage.
The Supreme Court’s ruling revolves around a contested medical report concerning injuries James Mordhorst sustained while working for Fischer Furniture in Rapid City, South Dakota, in 2011. While Mordhorst was making a delivery, a 275-pound sofa fell from the back of a truck and struck him on his head and shoulders, rendering him unconscious. When Mordhorst received medical treatment the following day, an MRI revealed a herniated disc in his back.
At the insurer’s request, Mordhorst was later examined by an “independent” medical examiner (IME), who concluded that the only injury sustained was a “strain” that had resolved 18 days after the accident. The insurer used the IME’s report as its basis for terminating Mordhorst’s workers’ compensation benefits on October 16, 2012. When challenged by the worker’s lawyer, the IME eventually abandoned his position about the injury being so short-lived, but the insurer continued to deny benefits. The South Dakota Department of Labor disagreed with the insurer, ordering the company to pay his past medical bills, interest, and future medical expenses.
“Workers’ compensation and auto insurers both often hire ‘independent’ doctors to examine injured people,” explained Nancy Turbak Berry, a veteran personal injury lawyer. “Typically, those doctors are nowhere near ‘independent,’ as they are selected and paid by the insurance company and usually are chosen because of a reputation for telling insurers what they want to hear. Their reports often are at odds with the opinions of treating physicians, yet many insurers like to rely on them to try to avoid paying benefits.”
Mordhorst subsequently sued the insurer for bad faith, alleging it had been unreasonable in denying him benefits. The circuit court granted the insurer’s motion to dismiss because it concluded that the insurer necessarily was justified in relying on the IME report to deny benefits. Reversing the circuit court, the Supreme Court noted that jurors are routinely expected to evaluate expert opinions and weigh them against countervailing evidence, saying insurers can be expected to do the same. The Court found that “an insurer’s basis for denial is not necessarily reasonable simply because the insurer relies on the opinion of a medical practitioner.”
“When an insurance company fails to consider all the relevant evidence before denying coverage, it can leave injured workers with little access to the medical care they deserve,” said Seamus Culhane, attorney at Turbak Law Office, PC. “The Supreme Court’s decision to reverse the dismissal of James Mordhorst’s lawsuit should compel other injured workers who have received conflicting medical reports to question whether they have legal grounds for a bad faith denial by an insurance company.”
If you believe your insurance company has unfairly denied your claim, contact the experienced attorneys at Turbak Law Office, PC. We can help you navigate the legal process and get the coverage you paid for.
For more information on what to do when your insurance claim is denied, contact Turbak Law Office, PC. by calling 866-231-0914.