Insurance has held my claim for nearly a year. No Movement or Contact.

[codeyell0]

Jurisdiction

Georgia

Not sure where this goes.
Had a slip and fall. (gov't facility but was covered by an insurance policy for the group working in this area)
Filed a claim with insurance they started and did the investigation but have not moved forward and they will not return or answer calls.
They have not denied the claim they just have not moved forward.
What can I do?

 

[Zigner]

Is this a new incident, or is this about your wife's fall last year?

Wife Slipped and fell in School doing PTA work

My wife is a sub, and PTA worker for the school. She is employed by the district. A few days ago she slipped and fell at the school. there was a water fountain that had water on the floor. The mat was wet and so was the floor. She was there doing PTA work as she was part of the PTA. She...

www.thelaw.com

 

[Redemptionman]

Is this a serious question? It appears they are calling your bluff. You will either sue or they will wait you out which is what they are doing. They measure risk and evidentially they don't think you have a case.

Have you talked to a personal injury attorney? they won't take the case unless they think they will win.

 

[army judge]

What can I do?

Seek a lawyer that's willing to undertake the case on a contingency basis, versus a set upfront fee.

Most such deals net the mouthpiece 1/3, you keep 2/3 less necessary expenses.

Yeah, it somewhat sucks, but isn't 2/3 of $50,000 worth more than 100% NOTHING????????

 

[codeyell0]

Is this a serious question? It appears they are calling your bluff. You will either sue or they will wait you out which is what they are doing. They measure risk and evidentially they don't think you have a case.

Have you talked to a personal injury attorney? they won't take the case unless they think they will win.

I figured they would deny the claim. Not just ignore us.

 

[codeyell0]

Is this a new incident, or is this about your wife's fall last year?

Wife Slipped and fell in School doing PTA work

My wife is a sub, and PTA worker for the school. She is employed by the district. A few days ago she slipped and fell at the school. there was a water fountain that had water on the floor. The mat was wet and so was the floor. She was there doing PTA work as she was part of the PTA. She...

www.thelaw.com

Yes, after everything we found out she was covered by insurance bought by the PTA. For PTA members.
The school originally said it was workers comp which it wasn't, Then Since its a school you can't do anything unless I can sue someone specific.

I wasn't sure if you could just sue insurance if they were "working on the claim"

 

[Redemptionman]

Who owns the policy? who is the policy holder, that is who will indemnify and defend the case.

Again, these companies just don't magically pay claims unless they can get out of it cheap. You need an attorney and a good PI one can get you some money. Probably along the lines of what Army said but still something is better than nothing.

 

[zddoodah]

Not sure where this goes.

You should have tagged this onto your prior thread about the same topic. Here's the initial post in that thread (that Zigner linked):

"My wife is a sub, and PTA worker for the school. She is employed by the district.
A few days ago she slipped and fell at the school. there was a water fountain that had water on the floor. The mat was wet and so was the floor. She was there doing PTA work as she was part of the PTA. She was with another person and multiple people saw her fall. My wife works as a substitute in the school she is a preferred sub.
We found out today that she needs surgery because she tore her ACL. The school doesn't offer medical for subs. Everything so far has been out of pocket.

What is our recourse? File a suit? Ask them to pay medical?
I'm afraid there will be ongoing medical to rehab her leg.
My wife is scared about filing or suing the school. Thinking she will not get any more work or be retaliated against, our kids are both in this school as well."


The conclusion in that other thread is that there's no workers' comp claim because your wife was not acting in the course and scope of her employment at the time of the accident. You also explained that neither of you had personal medical insurance at the time of the accident. Moving to your questions in this thread:

[My wife] Had a slip and fall. (gov't facility but was covered by an insurance policy for the group working in this area)
[My wife] Filed a claim with insurance they started and did the investigation but have not moved forward and they will not return or answer calls.

Just FYI, omitting the subject of the sentence at the start of your sentences can make things hard to understand. I assume my additions above are accurate, but please say so if not.

That said, what sort of insurance is this? Are you referring to the school's premises liability coverage?

we found out she was covered by insurance bought by the PTA. For PTA members.

OK...it's important to know if this is liability coverage under which the PTA is the insured or personal medical coverage under which your wife is the insured.

If it's liability insurance, then it's a third-party claim, which means the insurer has no or limited duties to your wife. If it's first-party medical coverage, then the insurer has significant duties to your wife. Either way, she can complain to the Consumer Services Division of the Office of the Commissioner of Insurance.

Beyond that, her only recourse is to sue the school and/or the PTA for negligence. I don't know if she has a viable claim, and this will be more difficult since the school is a public school, and there are specific processes that must be followed before you can sue a public entity. Conferring with an attorney is the thing to do. Note that there's a two year statute of limitations on negligence claims, and your prior thread indicated that the accident happened "a few days" prior to September 5, 2023.

 

[codeyell0]

You should have tagged this onto your prior thread about the same topic. Here's the initial post in that thread (that Zigner linked):

"My wife is a sub, and PTA worker for the school. She is employed by the district.
A few days ago she slipped and fell at the school. there was a water fountain that had water on the floor. The mat was wet and so was the floor. She was there doing PTA work as she was part of the PTA. She was with another person and multiple people saw her fall. My wife works as a substitute in the school she is a preferred sub.
We found out today that she needs surgery because she tore her ACL. The school doesn't offer medical for subs. Everything so far has been out of pocket.

What is our recourse? File a suit? Ask them to pay medical?
I'm afraid there will be ongoing medical to rehab her leg.
My wife is scared about filing or suing the school. Thinking she will not get any more work or be retaliated against, our kids are both in this school as well."


The conclusion in that other thread is that there's no workers' comp claim because your wife was not acting in the course and scope of her employment at the time of the accident. You also explained that neither of you had personal medical insurance at the time of the accident. Moving to your questions in this thread:




Just FYI, omitting the subject of the sentence at the start of your sentences can make things hard to understand. I assume my additions above are accurate, but please say so if not.

That said, what sort of insurance is this? Are you referring to the school's premises liability coverage?




OK...it's important to know if this is liability coverage under which the PTA is the insured or personal medical coverage under which your wife is the insured.

If it's liability insurance, then it's a third-party claim, which means the insurer has no or limited duties to your wife. If it's first-party medical coverage, then the insurer has significant duties to your wife. Either way, she can complain to the Consumer Services Division of the Office of the Commissioner of Insurance.

Beyond that, her only recourse is to sue the school and/or the PTA for negligence. I don't know if she has a viable claim, and this will be more difficult since the school is a public school, and there are specific processes that must be followed before you can sue a public entity. Conferring with an attorney is the thing to do. Note that there's a two year statute of limitations on negligence claims, and your prior thread indicated that the accident happened "a few days" prior to September 5, 2023.

What I know about the insurance policy, is the PTA pays for this policy for the PTA employees.
This is a third party separate from the school. I will reach out to the Consumer Services Division of the Office of the Commissioner of Insurance. If that doesn't work I'll start contacting a lawyer.
I was just curious about how to move things along. Thank you for the information.

 

[Redemptionman]

What I know about the insurance policy, is the PTA pays for this policy for the PTA employees.
This is a third party separate from the school. I will reach out to the Consumer Services Division of the Office of the Commissioner of Insurance. If that doesn't work I'll start contacting a lawyer.
I was just curious about how to move things along. Thank you for the information.

Okay, one thing to keep in mind is if you sue the school, your wife will never work there again.