GQ Corner

Q. I just received a claim from sedentary office employee with pre-existing heart condition.  She indicates the employer who is an Insurance Agent is aware she has issues with heat. The power did not work on 8/7/19 and she suffered heat exhaustion by her own account of the PCP appointment and subsequent ER visit the next day.

She indicates they have done blood work on two separate occasions to see if she has had a stroke?  Regardless she expects us to pay for ongoing care related to her heart including an MRI for her brain I am guessing to rule out a stroke?  HOW IS THIS WC RELATED?

A. If the claimant has medical establishing a link between her work activities and a diagnosis of heat exhaustion that could be compensable.  Without medical referencing that diagnosis and providing an explanation as to how that diagnosis is work-related, I would dispute the injury.  Even if heat exhaustion is compensable, I would dispute the compensability of the stroke (again, in the absence of medical evidence linking the stroke to the work activities).  The claimant may expect you to pay for a MRI of the brain, but if there is no medical evidence linking the need for the brain MRI to something occurring at work, the claimant’s going to be on her own for payment. 

Q. I received a DWC-69 and report on an IW; however there is a discrepancy on the forms.  The DWC-69 has a 1% and the report shows a 16%.  I fully believe the doctor intends for the IR to be 16%. I am pending receipt of the amended DWC-69.  

Before any action is taken, do I need to wait to receive the amended DWC-69 and report? Am I required to begin IIBs payments although there is a discrepancy or should I dispute if in disagreement with the 16%?

A. I would recommend responding to the report in its current form, and treating the IR as 16% since it sounds like the narrative makes it clear that this was the intended rating and that the DWC-69 merely contains a clerical error.

If this is from a designated doctor, you are required to pay the IIBs. If it is the first rating on the file and you wish to dispute, you must file a DWC-45 on MMI/IR within 90 days or else it may become final.

If this is from a treating or referral doctor, you may, but are not required to, initiate IIBs pursuant thereto. You may either “accept” the rating or dispute it and issue a reasonable assessment.

Either way, you would file a PLN-3 documenting your position with respect to the certification.