Injured restaurant employee claims insurer denied payment without investigation
GALVESTON - A Santa Fe woman alleges that her insurance company's denial of a job-related injury claim made her miss out on temporary monetary compensation and an essential medical procedure, recent court documents say.
Darlinda Bredehoeft's lawsuit against Ace American Insurance Co. Specialty Risk Services LLC says the defendant disputed her claim over her injured right knee "without conducting a reasonable investigation."
Bredehoeft had to endure a growing tear in her knee for approximately 10 months as her carrier sought authentication of the claim, the original petition argues.
The suit was filed Sept. 29 in Galveston County District Court.
The plaintiff explains that she injured her knee while she worked at Ryan's Steakhouse on Nov. 25, 2008. She immediately reported the injury to her employer and sought medical care, the suit states.
A week later, an orthopedist recommended Bredehoeft undergo an MRI. Meanwhile, Ace American received the claim and assigned an adjuster to investigate it.
Bredehoeft met with the adjuster to give a recorded statement.
The plaintiff said the injury she sustained while waiting tables at the Texas City buffet was minor, but insisted she overextended her knee to the point of excruciating pain, according to the original complaint.
The suit then points out that the defendant did not wait for the MRI results, therefore it filed a notice it was disputing "that any conditions beyond a knee strain were related and not sustained in the course and scope of employment" before properly investigating the matter.
The MRI taken on Dec. 10, 2008 revealed a partial tear in the anterior cruciate ligament, prompting surgery for Bredehoeft.
The suit asserts that the defendant sought a peer review on the MRI results in an attempt to buttress its denial, adding it provided limited information instead of what Bredehoeft said in her recorded statement.
The plaintiff's surgery was delayed, and her injury progressively worsened as the dispute carried on throughout the first half of 2009, it says.
In October 2009, a panel determined Bredehoeft's injury claim warranted past due temporary income benefits and the postponed operation, however, the suit shows the decision "came too late to avoid new and independent charges."
In addition to physical pain, the plaintiff consequently suffered unnecessary financial harm and mental anguish thus seeks unspecified monetary damages, it states.
Mayfield Weedon LLP is representing Bredehoeft, and Galveston County 405th District Court Judge Wayne Mallia is presiding over the case.
Case No. 10-cv-3753