Opinion ID: 2651525
Heading Depth: 3
Heading Rank: 4

Heading: October 5, 2006-January 16, 2007 (~14 weeks)

Text: State Farm argues its active investigation of James’s claim provides a legitimate or arguable basis for its delay. During this period of time, Powell acted on her concern that James’s injury may have pre-dated the accident. On October 5, 2006, Powell sent James a letter asking her to call to discuss the claim. The letter stated, “If I can obtain some of your prior records, I may then be in a position to evaluate your uninsured motorist claim.” On October 9, 2006, James disclosed to Powell that she had fallen on concrete over twenty years ago and had been treated for lower back pain at that time but had not been recently treated for any back problems. James also provided the names of all of her doctors to Powell. On October 10, 2006, Powell sent James an authorization for release of prior medical records. On October 19, 2006, Powell wrote James a letter, reminding her to return the medical authorization that would allow the release of her prior medical records. On October 27, 2006, James left a message for Powell, stating that she would not sign the medical authorization. The same day, Powell sent James a letter acknowledging James’s refusal. The letter noted in reference to some of the medical records State Farm had obtained, “As you can see, this does not clearly relate your ongoing treatment to an injury sustained in the accident and I am merely trying to determine if you had to treat for any of these pre-existing conditions prior to the accident [or] if they became 13 Case: 11-60458 Document: 00512514313 Page: 14 Date Filed: 01/28/2014 No. 11-60458 symptomatic following the loss. I do not know if I will be able to properly evaluate your claim without that information, but I am waiting on some information from Dr. Staggs at this time.” On October 30, 2006, James called Powell to let her know that she would sign the medical authorization. James then executed the prior records release on November 1, 2006, and State Farm received it on November 6, 2006. On October 27, 2006, State Farm sent a letter to Staggs, requesting all of James’s medical records. The letter elaborated, “I am trying to determine if [the thoracic compression fracture for which Staggs was treating James] was caused by the accident of February 3, 2006, since the intial radiology report indicated that this injury was probably old. If your notes do not comment on what injuries were caused in this accident or how the accident may have affected any preexisting injuries, please advise via letter.” State Farm sent Staggs a second request for James’s medical records on November 17, 2006. On January 16, 2007, Total Pain Care responded to State Farm’s medical records request but advised that records prior to August 14, 2006 needed to be requested from a different facility. Powell did not contact Staggs again. Seeking further clarification from the insured’s treating physician as to the cause of the insured’s injury is a legitimate basis for a delay of payment. Therefore, we conclude that State Farm’s actions in attempting to resolve its questions via James’s treating physician met State Farm’s low burden to provide a legitimate justification for its delay during this time period.