LAS VEGAS (KTNV) — Health insurance companies make sky-high profits by delaying and denying claims, often forcing patients into court to fight for the coverage they desperately need.
Las Vegas English teacher Brett Gilman has been embroiled in a five-year battle since he was injured on the job while trying to break up a fight at Garside Junior High School.
Even though his case is now officially closed, he's still in debt, waiting for his health insurer to settle his medical bills.
The student who forever changed Gilman's life was not supposed to be on campus that day.
"The behaviors of these children, so out of control..." said Gilman.
When a fight broke out on April 25, 2019, Gilman sprung into action.
"I was in the teachers' lounge. When I walked out, the place was literally in riot mode and they were chasing a student," he said.
A suspended student who slipped out of her backpack straps when Gilman tried to grab them as she ran by.
"I pursued her and then she looked right at a big, giant trash can. She looked right at it and threw it in my way and I slipped and went straight up in the air and landed straight on my tailbone. Lost my hearing aids, lost my ring, my glasses were bent. It was quite an incident," Gilman recalled.
Over the next couple of months, Gilman's back got progressively worse.
"I was getting radiating pains down my lower back and down my leg, to the point where I would literally freeze," he said.
The incident left Gilman with herniated discs and led to a spinal fusion surgery.
The battle to recover would be long, made all the more painful when his insurance through Teachers Health Trust started playing games with what they would cover.
"The insurer's attitude was, 'No. We're not going to pay,'" Gilman said.
Sierra Nevada Administrators — THT's insurance carrier — refused to pay bills involving Gilman's back because the initial workers' compensation form states he hurt his neck and thoracic region.
But his attorney, Javier Arguello, said the insurer missed something.
"The law actually changed back in 2009, and it said if an insurance company accepts a claim, they have to indicate what they're accepting or denying. But if they don't indicate that they're denying something specifically, it's not considered denied," Arguello said.
Because of that, Arguello was able to re-open Brett's claim, arguing the insurer never specifically denied the claim regarding his back.
The case went all the way to the Nevada Supreme Court, where justices ruled in Gilman's favor, stating Sierra Nevada Administrators must cover any expenses related to his back.
"It's frustrating. It's traumatizing. Quite honestly, it's not fair," said Gilman. "It's not fair — not just to me as a teacher — but the way this law was interpreted, it's unfair to workers everywhere."
Frustration with the health insurance industry is nothing new. You'll recall Luigi Mangione is charged with gunning down United Healthcare CEO Brian Thompson in Manhattan last month.
The motive? According to officials, the company was targeted because it's the largest health insurer in the U.S.
But violence against insurers has happened here in Nevada, too.
Back in 1993, Jim Forrester crashed his truck through the State Industrial Insurance System building on Charleston Boulevard at Shadow Lane. He then began firing at people with a shotgun and pistol, upset over losing benefits after he injured his back at work.
At the time, attorney Harold Needham said, "His benefits were terminated and when Jim heard that, that's all he heard. He basically, at that point, I believe, snapped."
Ultimately, a fraud agent shot Forrester, ending the attack. Forrester was sentenced to six years in prison and died in 2009.
"We still have delay, delay, delay," said Arguello, who explains that the average workers' comp case can take anywhere from six months to two years before finally being settled.
"I get a lot of cases of people whose claims are denied who shouldn't be denied," Arguello said. "We can file complaints, but the penalties are small. We're working on it, trying to get it bigger, but that's why the insurance companies can delay, I think, because they don't really get slapped that hard, and that's a problem because the only people suffering are people like Brett [Gilman]."
But Gilman's suffering will help others in the future. His name and case are now listed on workers' comp forms that insurance companies must send out because of the Nevada Supreme Court ruling.
"To see a ruling come down like this that I know is going to help more than just teachers...It's going to help construction workers. It's going to help delivery, all types of workers everywhere," said Gilman. "And so, I couldn't be happier. It means a lot to me. It means so much more than any amount of money."
Gilman is still hoping to get more money back as he waits on providers to reimburse him for the thousands of dollars he paid out of pocket.
If you need help with a job-related injury, here's what to do
If you've been injured on the job, you can consult with any workers comp attorney for free.
The attorney in our story, Javier Arguello, has seen the issue from both sides. He is an expert in workers compensation law, having worked as counsel for insurance companies for over a decade before moving into private practice to represent inured workers. If you'd like to reach out to him, you can do so here.
Arguello explains that most workers' comp attorneys don't charge any fees unless they win your case, cautioning that you should reconsider before signing with anyone who wants to charge fees upfront.
When seeking a worker's comp attorney, be sure to research them by checking online reviews and verifying their years of experience.
You can also obtain a referral through the Nevada State Bar by calling 702-382-0504.