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Workers Comp Claim Denial Means No Medical Control?

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Court of Appeals Confirms Workers Comp Claim Denial Medical Control Loss

Does a Workers Comp claim denial result in the claims staff losing medical control?  A long-standing debate among workers comp claims adjusters still occurs today.

picture of arm in sling workers comp claim denial
Public Use License – Wikimedia – Self

One outlook says the adjuster retains medical control on the file.  The denial may be removed later on in the claim.  The claimant should only expect covered medical treatment if they still see the “company doctor” and any referrals.

If the claim denial sticks, then the employee’s health insurance (if they have a policy) will cover the medical expenses.

The other side of the coin says the claims staff has no right to control the medical treatment when an adjuster issues a workers comp claim denial.  How can the injured worker treat with the employer’s (and adjuster’s) choice of treating physicians?

The other side of the coin seems to make more common sense.  One cannot control what one does not cover.  

The most important one of my Six Keys to Workers Comp Savings points to the use of medical treatment networks to keep costs in check.

North Carolina Court of Appeals

Stethoscope Workers Comp Claim Denial with green apple
StockUnlimited

Recently, the North Carolina Court of Appeals made this decision as part of a large case with more contentions than just medical control.    The case was

PAMELA LAUZIERE, Employee, Plaintiff,
v.
STANLEY MARTIN COMMUNITIES, LLC, Employer, and AMERICAN ZURICH
INSURANCE COMPANY, Carrier, Defendants.

You may find the case here if you wish to read the whole decision.  One of the three Justices wrote a very interesting dissenting (disagreeing) opinion.

The Appeals Court in North Carolina handles appeals after an Industrial Commission Deputy Commissioner and Full Commission (on appeal) have rendered their decisions.

A passage from the Court decision said:

As to the argument, Defendants were prejudiced by being unable to direct medical care, we have “long held that the right to direct medical treatment is triggered only when the employer has accepted the claim as compensable.”

This confirms, at least in the Tarheel State, that when a claim is denied, medical control goes to the injured employee’s choice of treatment.

One of the most upset physician’s offices I encountered in my adjusting career was when four years of medical bills were switched from health coverage to Workers’ Compensation as agreed to at a mediation.

Wow – the doctor’s billing staff was not happy!  The paperwork became a nightmare to reimburse the health carrier and then rebill to the comp carrier. BTW, the denial was wrongly issued by an adjuster that preceded me on the file.

Workers Comp Claim Denial – Medical Control Decision

Senior woman Workers Comp Claim Denial sits with plaster cast on broken arm
StockUnlimited

One aspect of a claim denial that many claim departments may miss centers around the loss of medical control.   Most denial decisions likely do not consider the amount of future medical payments if the claims are ruled compensable or if the adjuster decides to pay for the claim at a later date.

I am not referring to the file reserves.  The claims staff will likely reserve a file as if there is a risk that benefits will be paid out sometime in the future.  Full value reserves mean the employers will pay full value in their premiums.

If the file has no medical control a possible “rethink” needs to occur before the workers comp claim denial and its aftermath.

My hat is tipped to WorkCompCentral.com.   I found the worker’s comp case there.  It was behind a paywall, so I could not provide a direct reference.

The bottom line – losing medical control may offset a weaker workers comp claim denial.

 

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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

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