GQ Corner
Q. I received a claim from an insured because the bill collector told them that this was considered a work injury. On 5/18/19, she was on a business trip and became ill and by her own words, she doesn’t know why. She sought medical treatment in the hospital and was treated and released. She said it could have been a stomach bug or some kind of food poisoning, but she is not for sure. The claimant stated that she didn’t want to turn it in as workers’ comp because she feels that it’s not work related, but the collector was adamant that they turn in a claim so they did.
I just spoke with him and asked him for the medical records. I advised him if we determine that it is not a workers’ comp claim, we will file a PLN-1 for them to submit to her health insurance. He said that if we file a PLN-1 they “have” to request a BRC and have the claimant agree that this is not a workers’ comp claim via DWC-45. I told him that once we make our determination, the PLN-1 will suffice with the health insurance, a BRC will only be necessary if the patient/claimant disputes our denial. He said I was wrong!!! Am I missing something here? I know that I can deny the claim for not being turned in within 90 days…..
A. The provider may have its own internal procedures for proceeding in situations like this, but you should be covered with a PLN-1 regardless. It sounds like at a minimum you have a reasonable basis to dispute compensability and to raise a 30-day timely reporting defense. The provider could theoretically try to pursue dispute resolution proceedings as a subclaimant on the issue of compensability for billing purposes even if the claimant does not dispute the denial. From that standpoint, if the claimant is willing to sign a DWC-24 Benefit Dispute Agreement stipulating that she did not sustain a compensable injury that would probably be good because it should wrap up your involvement once and for all.
Q. I have a claimant that was seen by a DD a year ago and is currently in his 8th quarter of SIBS. The DD has him completely off work, but his treating doctor currently has him on light duty with restrictions. Do I need to keep sending him to the DD to get a light duty release or can I go with the new work status from the treating?
A. The treating doctor opinion provides strong evidence of an ability to work at least in some capacity, but the designated doctor opinion is presumed to be correct under the Act and you are bound by it unless and until overturned. The most aggressive approach would be to dispute SIBs entitlement (effectively disputing the designated doctor opinion but all the while continuing to issue benefits in accordance therewith) and argue in litigation that it is contrary to the preponderance of the evidence such that the Division should overturn it. Realistically, the odds of prevailing under these circumstances are extremely low. I think your best bet would be to pursue a new designated doctor exam and a post-designated doctor required medical examination.
FOLIO
