Negligence, Other Injury Insurance won't cover bills after 2 years from date of injury

[pushpin]

Hi,

I have 2 questions. First, about insurance coverage:
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My son was injured playing HS baseball and lost at least 4 adult teeth and the number may rise to 6 or 8. He will require implants but the work can't start for 3-4 years until he stops growing. We are being told our insurance, both BCBS and the athletic association's, won't pay for any expenses incurred after 2 years from the date of injury. What recourse do I have? Implants can run $5000 per tooth and there is no way I can afford this outside of insurance.

Second, about negligence:

The trainer did not call an ambulance even though he had a bad head injury, lost teeth, and was in shock. He was only evaluated for a concussion (which was negative). He also left my son alone and un-monitored for 30 minutes, during which time my son could have passed out. My wife had to drive an hour to get him, then another hour to a dentist, then more time to get him to the hospital. It was over 4 hours before he was seen and by that time it was too late for the lost teeth to be put back in with a chance to re-attach. Do I have a case for negligence, and if so against who? A PI lawyer told my wife there is no way to sue the school.

 

[Betty3]

You will have to abide by the ins. company's policy provisions & any "agreement"/contract that the athletic assoc. might have regarding this.

It seems you already talked to a PI attorney & he/she said you can't sue for negligence.

You could always run the entire situation by another attorney or two for additional opinions/advice re both your questions.

 

[Michael Wechsler]

If a personal injury lawyer decided that the case wasn't close enough to (a) a good very good chance of winning, and (b) enough money to make taking the case worthwhile, then chances are good that you'll have a difficult time going forward with another injury lawyer - although it's worth getting a second opinion. Suing the school would be very difficult, especially if you're talking about short periods of time where what might be possible are highly speculative. It seems like an accident occurred and a very unusual one at that. Your best bet is to check the policy carefully and see whether the insurance should apply to issues that arose during the time of the policy. If the insurance policy provides a cap on the boundaries of when liability will apply, then that is a term in the agreed upon policy. You may want to discuss this with an insurance agent as opposed to your insurance company who has little incentive to explain how issues like this are covered and handled generally. I'm guessing most injury attorneys, such as the attorney with whom you spoke, are probably familiar with such policies. Best of luck to you and especially your son.

 

[pushpin]

Thank you both for the advice. I am in the process of getting a copy of the Master Policy to understand the details of the two-year limit. I'm still asking if there is any case law that applies for extending such a deadline due to extenuating circumstances. Maybe an injured limb that eventually has to be amputated.

I do find it hard to accept that a trainer could look at my son, determine no concussion, and then tell him to have a seat for an hour while he waits for his mother, alone. He was bleeding, had 2 teeth knocked out, and went into shock. How could you not call an ambulance? How could you not continue to monitor for delayed symptoms and shock? I thought people were supposed to err on the side of caution in order to avoid a law suit. This person did not and now I'm told there is no case to pursue. Google teeth knocked out and it's common knowledge they should be put back right away to save them. His lack of action directly caused my son at least 2, maybe 3, teeth.

Sorry but I'm very frustrated and it seems like the system is set up for everyone to skate away clean while I pay all the bills.

 

[Michael Wechsler]

I completely appreciate where you're coming from. It's frustrating and you feel wronged.

The trainer may have been negligent but don't mistake what I am saying - not the attorney. I am saying that you may have a lawsuit for negligence. But if you want a personal injury attorney to pay for the cost of prosecution in order to obtain a potential award or settlement, chances are that may not happen. If you're willing to pay the attorney by the hour, I'm sure you'll find plenty of attorneys to take the case. My guess is that they think the hours involved will exceed the value that they will receive.

Most importantly - why did the attorney say that you have no case? The problems you may have are proof issues, e.g. that the teeth could have been put back in but for the negligence of the trainer. How long would it take for an ambulance to arrive? How long would it take to get to the emergency room? How long will it take for them to begin to put the teeth in and the chances that they might take? I believe that the ideal situation isn't that long, perhaps a half hour to an hour at most. Were the teeth chipped, cracked or broken as a result of the ball striking them? There is a good chance that some tooth damage did occur.

Regarding the 2 years on the insurance policy - it's contractual. Case law wouldn't really apply since you are bound by the terms of the agreement. If you want better coverage for 10 years then perhaps there is a policy for that. There are special policies baseball teams get and almost anything can be insured if you're willing to pay.

I'm extremely sympathetic. This is a tough situation for you and, even moreso, for your son who is missing his front teeth and a constant reminder to you. The best I can say is get a second opinion. There aren't any easy answers when you're in the gray zone. Best of luck to you both.