No-Fault Coverage: Lost Wages and Medical Debt – Case Study

Our client was involved in a car accident in May of 2012 when an 18-wheeler rear-ended them on the Long Island Expressway. From the collision, they suffered a severe concussion and injuries to their neck and back. At the time of the accident, they worked as a social worker and due to their injuries, they were disabled and could not return to work. Initially, their insurance company paid their lost wages for the time they missed from work. However, in August 2012 they stopped paying because they alleged they had not filled out or submitted the proper documentation.

When the insurance company stopped paying their lost wages, they were placed in a difficult situation as they had no income to pay their bills. Faced with eviction from their landlord, they were forced to attempt to return to work despite the severe pain they were in. Unfortunately, their employer at the time of the accident had filled their position while they were on disability and could not rehire them. Our client was lucky to find a position with a new employer but was only able to work one month before they had to resign as their injuries made working unbearable.

Around this time in December of 2012 the insurance company sent them for an independent medical exam (IME), which determined that they were no longer disabled and their injuries had resolved. Based on this exam the insurance company stopped paying for medical treatment under no-fault.

As our client’s injuries from the accident were still causing them intense pain, they had to use their private health insurance for all the medical treatment they received. Over the next year and a half, the bills for this treatment totaled nearly $10,000.00.

Until they were approved for Social Security Disability in March of 2013, our client had no income at all as they were disabled and they went into substantial debt as they had no other way to pay their bills and living expenses.

In 2014, the client’s case against the 18-wheeler that hit them settled and they received a substantial sum. However, the settlement amount was reduced by nearly $10,000.00 as their private health plan was ERISA (Employee Retirement Income Security Act) based. This means that in the event of a settlement, the ERISA plan was entitled to get all the money they paid for medical treatment back. 

This is when the client was referred to our office to pursue their insurance company for the $10,000.00 that our client was now out of pocket. Had their insurance company not stopped paying for medical treatment based on the IME, these medical costs would have been covered. At a hearing, a no-fault arbitrator determined that our client’s injuries had not resolved at the time of the IME, and therefore the insurance company had to pay our client back for the full $10,000 lien they paid out of their personal injury proceeds.

Further, our client also had a claim for the wages that the insurance company improperly stopped paying. After a long and intense legal battle with the insurance company over the course of 3 years, we were able to secure approximately $30,000.00 in wages for the time our client was disabled from August 2012 to November 2013.

Car accidents can change someone’s life forever. In this case, our client lost 2 jobs, was forced to move, went into tens of thousands of dollars of debt, and still has residual physical pain from the accident even today. No-fault coverage is supposed to ensure that you can pay your bills and get the care you need in the event of an accident. It is one of the reasons you pay your auto insurance premium every month. The case above shows that sometimes your insurance company cares more about profits than you. When this happens, our firm fights to get the no-fault benefits you are entitled to under your auto insurance policy.

Total recovery to the client after their personal injury case settled:  $40,000.00

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