JL_risklogo.png

Workers Comp Audit Stress Reducer
Use It For Your Next Premium Audit

North Carolina Supreme Court Decision 4 Work Comp Claims All States

Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn

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.

graphic north carolina supreme court scales
Wikimedia Commons – DTR

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.

Picture Of North Carolina Supreme Court Room
Wikipedia – John L Marino

**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

Female Judge North Carolina Supreme Court Holding Hammer
(c) StockUnlimited

JOHNNIE WILKES, Employee
v.
CITY OF GREENVILLE,
Employer, SELF-INSURED

(PMA MANAGEMENT GROUP, Third-Party Administrator)

Conclusion

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.

©J&L Risk Management Inc Copyright Notice

Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn

2 Responses

  1. Wonderful work! This is the kind of information that are supposed to be shared around the web. Disgrace on the seek engines for now not positioning this put up higher! Come on over and consult with my website . Thanks =)

Comments are closed.

Table of Contents

Related...

James Moore

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Mgmt Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications

Subscribe

Get the latest workers' comp news FREE!

Name
This field is for validation purposes and should be left unchanged.