GQ Corner
Q. We have a claimant who has a serious compensable leg injury. He fell at home resulting in the need for dental treatment. He refused to answer if he was using his walker at the time of the fall. Is this an instance where we would automatically pay for the dental work, or could we investigate for possible denial?
A. The issue of whether a subsequent or follow-on injury was caused by a compensable injury, is a question of fact that ultimately has to be resolved by an ALJ (see AP 032646). If you do not believe the facts or evidence support that the compensable leg injury resulted in the fall that then caused his dental injuries, you can certainly file a PLN-11 to dispute those additional injuries caused by the fall. In addition, damage or harm that results from the failure of a claimant to comply with doctor’s instructions is not included within the scope of the original compensable injury (see AP 050105-s). If he was instructed to use his walker and did not, and that resulted in his fall and subsequent injuries, you can dispute via PLN-11.
Q. I have a firefighter who as injured on 5/2/19. IW went on to have posterior and anterior lumbar fusion and has been off work since the event. I received a DWC-6 that the IW resigned as of 09/29/19. Can TIBs be canceled due to the IW choosing to resign versus being let go?
A. If the claimant has returned to light duty at the preinjury AWW, and if there is then a resignation, then there is no disability and the claimant is not entitled to TIBs in the absence of a changed condition. If the claimant has returned to light duty at lower than the preinjury AWW, then he is, by definition disabled during the time that he is working. If there is then a resignation, disability continues in the absence of a changed condition and the claimant is entitled to TIBs. The amount of TIBs depends upon whether there is a written bona fide offer of employment. If there is no written bona fide offer of employment, then the claimant is entitled to full TIBs, regardless of the fact that he resigned. However, if there is a written bona fide offer of employment, then the claimant is entitled to partial TIBs, based upon the terms of the bona fide offer of employment. The notion is that the claimant’s resignation constitutes a de facto rejection of the bona fide offer of employment.
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