Arrow Electronics Inc.

Below is Service Lloyd’s response to Compliant ID =[redacted].   In return for the payment of premium, and subject to all of the terms and conditions of the policy, the GAP policy referenced in the complaint agrees to pay the difference between the balance of the insured’s financing agreement for...

the vehicle and the vehicle's actual cash value as of the date of total loss in the event of a total loss occurring within the coverage territory.   During the investigation of the claim it was identified that the vehicle had higher than normal mileage. The policy holder was contacted and asked how the vehicle was being used. The policy holder reported that it was being used as a daily newspaper delivery vehicle, driven 70 to 80 miles a day in additional to normal usage.   This usage is excluded under the terms and conditions of the policy: Defined terms: Commercial Purpose: If your vehicle is used on a regular and dominant basis for any of the following functions, you are not eligible for GAP coverage: rental, taxi, limousine or shuttle, delivery, towing or road repair operations, construction, job site activities, hauling, police or emergency vehicles, principally off-road use, racing or competitive driving, snow removal, and route work (service or repair). Additionally, under Exclusion #8 (commercial purposes).   The claim was denied and a full refund of the policy was paid to the lien holder in the amount of $1073.55    Please let us know if there are any questions or if any action is required on our part.   Thank you     [redacted] Director of Claims

Please find attached the response to the above mentioned complaint.  Thanks.Mr. [redacted] –Claim # [redacted] had a work related injury on 5/3/16.  The injured employee was washing a car when a co-worker hit the car he was washing and the door of the car hit the injured employee on the...

right arm and right hand. The injured employee was diagnosed with a right shoulder sprain/strain.  He was treated with physical therapy, injections and medication.  An MRI was done on 6/28/16. Service Lloyds had the MRI reviewed and it was determined that the MRI findings were consistent with pre-existing degenerative changes not consistent with the reported mechanism of injury or the post injury examination findings.  The MRI findings would support a pre-existing, age related ordinary disease of life.  It was reported that the mechanism of injury could be consistent with the compensable injury of a resolving right shoulder sprain. The carrier denied all conditions diagnosed on the right shoulder MRI as they were pre-existing and degenerative issues.  The carrier continued to accept as the compensable injury a right shoulder sprain, right arm contusion and right pinky dislocation.  Claimant was notified in writing on 8-8-16 of the denial regarding the MRI findings.  The injured employee left message with the adjuster on 9/13/16.   Contact was made with the injured employee that same day.    He was inquiring about a referral to an orthopedic surgeon because his treating doctor thought there might be a tear to the shoulder.  Adjuster explained that we were only accepting a right shoulder sprain/strain.  The findings on the MRI were disputed as non- compensable. Also explained that we were not denying his claim that he could follow through with an orthopedic referral.  The adjuster made a call to the orthopedic doctor claimant was referred to but they were not in-network and they would not set an appointment for the claimant. A field case manager was requested to assist in locating an orthopedic and awaiting appointment date. Service Lloyds had requested an appointment with a Designated Doctor thru the Division of Workers Compensation to determine whether the injured employee had reached Maximum Medical Improvement and Impairment rating.  The designated doctor was not asked to address extent of Injury.  The injured employee attended the scheduled appointment on 9/15/16.  Per the designated doctor’s report, the injured employee had not reached maximum medical improvement.  Per Section 408.0041 if the carrier is not satisfied with the opinion rendered by the designated doctor, the carrier may then request a division order for the claimant to be seen by a doctor selected by the insurance carrier.  The appointment is scheduled for 10/27/16.  The injured employee has an appointment with the Designated Doctor scheduled for 10/26/16 to address the extent of the compensable injury. The claim has been handled appropriately following the rules and regulations as outlined in the Texas Labor Code when a dispute regarding extent of injury arises.  The appropriate course of action is for the claimant to attend the designated doctor appointment to address the extent of injury.   The claimant is able to see an orthopedic specialist.  Service Lloyds will continue to pay reasonable and necessary treatment for the compensable injury which is limited to the shoulder sprain/strain.   Treatment for the disputed conditions will continue to be denied until its resolved through the appropriate course of action as outlined in the Texas Labor Code.  The carrier continues to pay the injured worker Temporary Income Benefits while he remains off work.  The carrier denies the claimant’s allegations that the claim has been handled inappropriately.