Owner-Operator Independent Drivers Association, Inc. (OOIDA)

The claim for this member is currently active and is still in process

This email is in reply to complaint #***. The
insurance plan that this member had was an Occupational Accident Plan.
Inter-Americas Insurance Corporation, Inc., (***) is the claim administrator
for
the Atlantic Specialty Insurance Company’s (ASIC) Occupational Accident
Policy that is issued to Owner Operator Independent Drivers Association, Inc
(OOIDA). OOIDA offers this plan to its members who are Owner-Operators or
drivers who are not required by law to carry statutory Workers’ Compensation.
These plans offer coverage for accidental medical, accidental dental and
dismemberment. The plans also offer limited medical, dental &
accidental death and accidental death and dismemberment benefits for
non-occupational accidents.
The claim submitted by this member has not been
denied. *** is having an issue confirming the date of the accident/injury
and obtaining confirmation of the date and dispatch for that date, with the
motor carrier the member leased withThe member has active health insurance
which is primary to the Occupational Accident Plan. There has been
correspondence and documentation between *** and the member, with the most recent letter being
sent to him on March 2, which explained *** is continuing to investigate
the matter, and informing him that while continuing their investigation of the
claim, they are proceeding under a Reservation of Rights. Stating they
are not waiving any rights provided under the policy provisions involving
investigation, coverage and/or payment of benefits pursuant to the
policy. They are reserving their rights due to the fact that
during the investigation, they have multiple dates of loss reported and they
are unable to confirm his dispatch with the motor carrier he was leased to at
the time of the reported accident/injury. They have stated as soon as the
date of his accident/injury is pin-pointed and dispatch is confirmed for that
date, coverage will be determined under the Occupational Accident medical
and disability benefits. In the meantime, ASIC did determine and instructed *** that the
claim will be covered by the limited Non-Occupational Accident Benefit until
the time they can confirm and verify dispatch by the motor carrierThe
Non-Occupational Accident Benefit does offer an Accident Medical Expense of Ten
Thousand Dollars ($10,000) but has no disability benefits
The following is a timeline of the claim:
October 29,
2015, the member called OOIDA requesting information on how to
report a claimHe stated the injury
occurred about a month ago, but was unable to provide the exact date of
injury. He was provided the information and
instructions to call & report a claim to the claims reporting line
November 3, 2015, an OOIDA Agent returned a call to
the member regarding his claimHe stated he was injured on the job on
10/21/and having shoulder trouble and needs an MRI. He stated his
health insurance plan will not cover it. Member was again provided
the information and instructions on how to call to report a claim
November 4, 2015, a loss was reported to ASIC by the
motor carrier of the memberMotor carrier reported the date of loss as October
21,
November 4, 2015, an acknowledgment letter and claim
form were mailed to the member
November 4, 2015, *** requested and received an
electronic copy of the Occupational Accident Enrollment form from OOIDA,
showing the effective date of the members coverage was July 19,
November 5, 2015, *** claim adjuster called and left
a voice mail for the member requesting a return call
November 5, 2015, *** claim adjuster called one of
the medical providers that treated the member and supplied billing information
November 5, 2015, the member provided a recorded
statement of loss to the *** claim adjuster, he informed the adjuster the
original date of injury was September 27, 2015; he was having trouble cranking
the legs up on a trailerThe crank came out and threw him onto his left
shoulder and left sideThe next injury occurred on October 21, 2015, when he
went to climb into his truckHe stated his left arm couldn't support him and
he fell from the truck to the ground but did not sustain injury
November 5, 2015, the adjuster emailed the member a
request for a completed claim form and copies of the Driver's Log and Bill of
Lading for September 27, 2015, his Independent Contractor's Agreement with the
motor carrier, his Commercial Driver's License, his federal tax return, a
work release from a physician, his health insurance plan information, and any
other documentation he may have from a treating physician
November 9, 2015, a request for dispatch confirmation
for October 21, 2015, was faxed to the motor carrier
November 9, 2015, the member called and informed the
*** adjuster that he needed to correct the date on his claim to September 16,
November 10, 2015, the member called and informed the
*** claim adjuster that his motor carrier seemed unsure of the date of injury
and whether it was March 16, or March 17,
November 16, 2015, a request for dispatch
confirmation for October 21, 2015, was faxed to the motor carrier
November 19, 2015, a request for dispatch
confirmation for October 21, 2015, was faxed to the motor carrier
November 19, 2015, the *** claim adjuster received
the members’ claim form reporting an injury date of September 15, 2015, his
federal taxes consisting of pages, and Commercial Driver's License
In the claim form, the member recorded that he works 12-hours per day,
days a week, and that he sits the majority of time he is on dutyHe did not
include any percentages for lifting/carrying/pulling
November 19, 2015, requests for medical records were
faxed to the chiropractic office and other providers
November 25, 2015, the member sent a fax to the ***
claim adjuster consisting of a providers completed information sheet and a
Medical Disability Form completed by his treating physicianThe form dated
November 17, 2015, indicated the member’s neck/shoulder disability began on
September 21, Of note, September 16, 2015, was listed as the initial
disability start date, then redacted and replaced by September 21, The
Medical Disability Form completed/dated November 25, 2015, by a treating
physician, indicated the member could return to work, full duty driving but
restricting him to an hour day and no lifting/carrying/pulling
November 25, 2015, the member faxed driver's Logs to
the *** claim adjuster for October 21, and of
November, 25, 2015, a request for dispatch
confirmation for October 21, 2015, was faxed to the motor carrier
November 30, 2015, the adjuster received the members
Bill of Lading/Trip Summary Sheet for October and 21,
2015, and his Independent Contractors Agreement
November 30, 2015, the motor carrier responded to the
adjuster's request for dispatch advising that they could
neither confirm nor deny that the member was under dispatch
on October 21, 2015, as he was not logged into the motor carriers electronic
log system
November 30, 2015, the *** claim adjuster followed up
on the request for medical records from treating providers
December 7, 2015, the adjuster followed up on her
request for medical records from treating providers
December 8, 2015, a Reservation of Rights was mailed
to the member
December 18, 2015, the *** claim adjuster received
medical records from a treating provider and a note from
October 05, 2015, that indicated the member’s shoulder had
been bothering him for 2-months from a work related incident when he heard a
popping noise while using a crank
December 19,the *** claim adjuster received a
faxed statement from the member in which he states; he sustained a work related
injury while using a crank, his primary health insurance carrier denied an MRI
as the injury was work related, he was forced back to work he stated, because
*** did not pay him any benefits for the month he was off work, and he is still
in pain
December 21, 2015, a request for dispatch
confirmation for September and 27, 2015, was faxed to the motor carrier
December 28, 2015, a Reservation of Rights was mailed
to the member informing him that the claims office is in receipt of multiple
dates of injury for his claim and have been unable to confirm dispatch with his
motor carrier
January 4, 2016, a request for dispatch confirmation
for September 16, 2015, was faxed to the motor carrier
January 7, 2016, the *** claim adjuster received an
email from the member in which he wrote that his motor carrier’s night dispatch
supplied him with the correct date of injury, October 16,
January 8, 2016, the *** claim adjuster received an
email from the member stating the date of his injury was September 16, not
October
January 11, 2016, a request for dispatch confirmation
for September 16, 2015, was faxed to the motor carrier
January 12, 2016, a representative from the motor
carrier, called the adjuster and stated he didn't want to fill out the request
for dispatch for the injury date September 16, 2015, as the date on the first
dispatch confirmation form (October 21, 2015), was the date the member called
the injury into them
January 14, 2016, the *** claim adjuster followed up
on medical records requests to two providers
January 26, 2016, the *** claim adjuster received an
email from the representative of the motor carrier, with electronic Driver's
Logs attached for date September 15, and 17, All three logs indicate
the member was off duty
February 6, 2016, the *** claim adjuster followed up
on a medical records request to a provider
February 11, 2016, ASIC instructed the *** Claim
adjuster to pay the members medical bills under the Non-Occupational Accident
Medical Expense Benefit on a secondary basisHowever, the date of injury and
dispatch would still need to be confirmed with supporting documents before
Occupational Accident medical and disability coverage could be considered
February 12, 2016, ASIC received a consumer complaint
via the Pennsylvania Insurance Department and provided a written reply dated
2/15/
March 2, 2016, *** sent the letter to the member
explaining they are paying the claim under the Non-Occupational Accident Medical
Expense Benefit on a secondary basis and explained the investigation of his
claim will continue under a Reservation of Rights. Stating the date of
injury and dispatch will have to be confirmed with supporting documents before
Occupational Accident medical and disability coverage can be considered
March 15, 2016, the member called OOIDA and spoke to
an Agent regarding his claimExplained he was under load when he was hurt and
gave a recap of his injury. He stated he had an MRI and now needs to see a
specialistHe stated to the Agent that the accident happened on September 16,
The OOIDA Agent informed him that he would make a call to *** and speak
to the claim’s department regarding his claim and speak to the supervisor and
he would probably have the claim supervisor call him back
OOIDA will continue working in good faith on behalf of our
member with the claims office and insurance carrier to ensure that a complete
and accurate investigation of the claim is conducted
***
***
Manager
Medical
Benefits Group
Owner-Operator
Services, Inc

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed as Assumed Answered]
Complaint: ***
I am rejecting this response because:***, I took a week off to try and relaxI just now got your emails This has not been solvedI have a pinched nerve and the insurance company is offing me cash to go awayIf I need an operation this could cost 100,dollarsI was hurt two different timesI tried to push through the first whip lash and not file because the insurance only pays per week after being out more then at least one week and my truck needs a few thousand a week to pay the billsThat's why there is no way in living hell that anyone one would try and fake being hurt because the insurance is inadequate! Please do not close this outEvery word I wrote about this is true
Regards,
*** ***

CTCM does not discuss Insurance claims with outside entities as a protection to our Insureds. However, we can advise this matter has been resolved.