GQ Corner
Q. I want to pursue a post-designated doctor RME and wanted to know if we can add extent of injury. I know the post-designated doctor RME can only address issues the designated doctor was appointed on. I am hesitant to pursue a separate designated doctor on that issue as it would likely result in an adverse opinion since the designated doctor is already including the disputed conditions.
I believe we should pursue the RME on MMI/impairment rating and then request the RME doctor to complete a peer review on extent of injury. The peer opinion could perhaps carry more weight since the doctor also examined the claimant.
What is your recommendation?
A: Your pursuit is spot on. Get the RME on MMI/impairment rating and then subsequently request a peer review from that doctor addressing extent of injury.
Q: I have a claimant who was denied MMI with a 23% impairment rating by the designated doctor. I requested a post-designated doctor required medical examination and the claimant was a no-show. In this case, what can I do?
A: Unfortunately, you cannot suspend the payment of IIBs based upon the no-show; you’ll need to continue paying per the designated doctor report. I would request a BRC and if the claimant attends the BRC, the Benefit Review Officer will tell him attendance at the BRC is not optional. If the claimant no-shows for the BRC too, you can request an Interlocutory Order to suspend benefits, though those are rarely issued. These cases are tough because the carrier has little power to force the claimant to attend the RME in this situation.
Q: Can we use a peer review to dispute benefits? Further, if we have a PLN-11 on file and the treating doctor continues off work or restrictions for the disputed condition, can we terminate benefits? I have noted Rule 129.2 (a): Once temporary income benefits (TIBs) accrue, an injured employee is entitled to TIBs to compensate the employee for lost wages due to the compensable injury during a period in which the employee has disability and has not reached maximum medical improvement.
A: You are correct: disability and the entitlement to TIBs are premised on the inability to maintain pre-injury earnings being a result of the compensable injury. If you have a peer review that questions the compensability of a condition, or conditions, you can certainly file a PLN-11 disputing said condition(s). If the claimant’s inability to maintain his pre-injury earnings is due to the condition(s) you are disputing, you can then also dispute disability and suspend TIBs. There is one caveat, though; if the designated doctor has opined the condition(s) is compensable, and/or has opined the claimant’s disability is a direct result of the injury, you are obligated to continue the payment of TIBs.
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