GQ Corner

Q. The claimant has missed her second DD appointment, along with the RME. Would you recommend filing the request for the BRC? What are my options?

A. First, you can suspend TIBs based on the claimant’s failure to attend the appointment if you have not already. You could have done so on the basis of her missing the RME too.

Second, you do not necessarily have to ask for a BRC on this matter if you have suspended TIBs and she is not treating. You could just wait and see if she turns up. You can also contact the treating doctor to see if he/she will see her and place her at MMI, but there does have to be an examination.

Third, you can file a complaint based on the fact that the claimant ignored DWC orders and missed two DD exams and one RME exam. You can find the form to file a complaint with the agency’s C&I department here:

http://www.tdi.texas.gov/forms/dwc/dwc154compl.pdf

Q. I have no way of knowing with any degree of certainty what claimants do away from work. Can you suggest a strategy to deal with the issue of “I woke up and by back was sore/hurting, etc.” This is getting to be prevalent for one of my insured. Any ideas? Should I deny compensability based on the assertion by the claimant that he just woke up sore?

A. No one has any degree of certainty about what people do away from work. “I just woke up sore” can be a red flag that there was not an actual accidental injury. I think immediate interviews and investigation is important in these matters. As you know, a claimant will often “remember” something that happened at work a few days after reporting he is sore, so getting the claimant to document his or her complaints ASAP is important. The employer needs to ask if there was anything specific that happened at work and document that conversation and have the claimant write a description of the injury. Get a recorded statement as soon as you can also, and explore pre-existing problems and complaints.

These cases have to be dealt with on a case-by-case basis, as the facts will dictate whether there is genuinely a compensable injury.