Thank Goodness for Awesome Claims Adjusters!

Keith More

Last week his authorized primary treating physician recommended he undergo an X-ray of his abdomen, a physical therapy evaluation for his upper extremity, and an evaluation with a psychologist.  Lo and behold, Genex sent the RFA to Dr. Fred Sutton Jr. a gastroenterologist out of Texas.  Dr. Sutton an Associate Professor at least from what the internet shows denied the X-ray of the abdomen, denied the physical therapy, and denied the psychological exam.

The abdominal X-ray was denied because Dr. Sutton states, "visually examining the various areas … can identify structures probably due to adhesions…" the UR noncertification isn't really clear on the denial and shockingly doesn't say he was shot in the abdomen and needed his bowel to be resected. Dr. Sutton goes on to say in the noncertification of the PT evaluation that he recommends strengthening exercises for the treatment of patients with shoulder disorders.  Really, a gunshot to the shoulder is a shoulder disorder!! Then to add insult to injury, Dr. Fred Sutton states in the noncertification for a psychological evaluation that "a psychological evaluation is recommended as part of the evaluation and management of patients with chronic pain…".

I can't make this stuff up as it happens almost every day.  My client was shot multiple times, and he can't get a stomach X-ray to see how the resected bowel is progressing, he can't get an evaluation with a physical therapist to determine the type of therapy he requires after taking a bullet to the shoulder, and he is denied a psychological evaluation after almost being murdered. 

Here is the good news, I called the adjuster and left a message for her, and she immediately jumped on this UR and overrode each of the above. My hat goes off to Amy Norman at Berkshire Hathaway GUARD Insurance Company for doing the right thing and avoiding the expenses of appeals etc.

Click here if you want to see documentation regarding this story, please contact Keith More.