GQ Corner
Q. I have a claim where the employee is claiming mental stress due to heavy workload and implementation of a new payroll computer system. She works as a Payroll Tech and she states that her workload increased in January of 2021 and increased with the implementation of the new payroll computer system in June of 2021. She states that she was working 7-10 hours more a week, her normal work days/hours was Monday-Thursday from 6:30am-5:00pm. She does not work on Friday’s as the office is closed. She did not report this claim until 09/16/2021, which is the date she is using as the date of loss. She originally filed this as a short-term disability claim and was told by that Carrier that she should file this as workers’ comp. She has been treating with her primary care doctor since 09/16/2021 under her personal insurance (we do not have any medical records). She also has been seeing a counselor since 9/22/2021 (she was not referred) found doctor herself. Would this be considered a work related stress claim?
A. Repetitive stress claims are not compensable and that appears to be what you are dealing with in this case. The claimant has not pointed to a specific date/time/event (such as a robbery, which is a prime example of a mechanism of injury that can yield a compensable mental stress claim). Any potential mental trauma diagnosis is complex in nature and, thus, subject to a dispute on lack of expert opinion; therefore, it may be appropriate to request a peer review once the carrier has obtained a complete set of medical records; and 2) mental trauma claims arising from legitimate personnel actions are not compensable.
Q. We received a DWC-69 from the treating doctor, which rated a disputed diagnosis. We sent the PLN-11 and the peer review to this doctor letting them know what is being denied and accepted. Can we file a PLN-11 or dispute this report somehow for being inaccurate?
A. Because this certification was issued by a treating doctor referral, and not by a designated doctor, you may either pay or dispute it. Given that it takes into consideration diagnoses the compensability of which are in dispute, it would likely be a good candidate for dispute. You would respond to the certification by issuing a PLN-3b and noting your position with respect to the certification. If you dispute, you check the box indicating that you disagree with the rating and are instead making a reasonable assessment of impairment. Also, keep in mind that if this is the first certification of MMI/IR on the file, it is subject to becoming final if not properly disputed within 90 days of receiving delivery of written notice of the certification by verifiable means. If a designated doctor had already been appointed to evaluate MMI/IR when the referral doctor issued this certification, you would need to file at least a DWC-45 on MMI/IR in order to dispute. Conversely, if a designated doctor had not previously been appointed to evaluate MMI/IR when the referral doctor issued the certification, you need to file either a DWC-32 to request a DD on MMI/IR or file a DWC-45 requesting a BRC in order to dispute the first certification/impairment rating.
FOLIO
