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.
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
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,
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
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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