North Carolina Supreme Court Ruling On Medical Treatment Denial After Initial Acceptance
The North Carolina Supreme Court has ruled on denying a medical condition after the claim was accepted. The link to the decision can be found at the end of this article. The file is in PDF format. The North Supreme Court decided in favor of the plaintiff . The case centers on the Parson presumption in a prior case revolving around the filing of the North Carolina Industrial Commission Form 60.
You should review this case even if you do not have interests in or have workers in North Carolina. I expect to see this ruling again in other states.
In North Carolina, The Form 60 basically represents the employer and carrier or self insured and Third party administrator admit compensability for the claim. The Form 63 enables the claims adjusting staff to pay up to 90 days of benefits without admitting liability.
If you look at the Form 60 and Form 63 closely you will immediately see the Form 63 gives the claims staff enough time to thoroughly investigate a claim before acceptance. Much debate occurs with the choice of what form to use. In my old claims adjusting days, I chose the Pay Without Prejudice Forms as much as possible. New Hampshire was the first time I had seen a Pay Without Prejudice Form.
Leading defense law firms discouraged the use of the Form 63 when I asked them. One statistic that stands out is that the claims were later denied by me less than 1% of the time.
The North Carolina Supreme Court ruled that once the employer/carrier or self insured/TPA accepts the claim and the employee proves an underlying medical condition was related – the injured employee’s claim for the specific medical treatment cannot be denied later in the claim.
**Please note that I am making a few assumptions as without the claim file to review, one must be very light on their opinions of how the case was handled. I am not asserting a claims handling opinion.
Some defense attorneys deem this case as one of the most significant decisions in Workers Comp for the last 30 years.
One that comes to mind for me was the 1994 North Carolina Supreme Court decision that erased the Statute of Limitation on all Workers Comp claims for medical treatment. The State Legislature later changed that one. One of the Supreme Court justices in 1994 said the case was social legislation. The big concern was the Workers Comp rating system was not built for this type of claim medical treatment alterations.
The North Supreme Court conclusion is below. The link to the decision is here. This is one to print or save to your desktop and read.
The case of
JOHNNIE WILKES, Employee
CITY OF GREENVILLE,
(PMA MANAGEMENT GROUP, Third-Party Administrator)
In sum, we hold that the Commission erred in failing to give plaintiff the benefit of a presumption that the additional medical treatment he sought was for conditions related to his compensable injuries. The Commission will reevaluate its decision, applying the correct presumption. As the Court of Appeals correctly addressed this error, we affirm on this issue. On the issue of plaintiff’s entitlement to additional disability benefits, we hold that the evidence raises factual issues regarding the effect of plaintiff’s compensable tinnitus on his ability to earn wages, and that, on remand, the Commission must find these facts. Accordingly, on this second issue we modify and affirm the decision of the Court of Appeals. We remand
this case to the Court of Appeals for further remand to the Commission for further proceedings not inconsistent with this opinion.
AFFIRMED IN PART; MODIFIED AND AFFIRMED IN PART, AND REMANDED.
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