GQ Corner
Q. The employer paid the burial expenses in a death claim on behalf of the widow. The burial expenses amounted to $12,000. Would the carrier reimburse the employer or the widow, and how much would the carrier reimburse?
A. The carrier would reimburse the employer for the burial expenses in the amount of $6,000. Section 408.186 states, “If the death of an employee results from a compensable injury, the insurance carrier shall pay to the person who incurred liability for the costs of burial the lesser of (1) the actual costs incurred for reasonable burial expenses, or (2) $6,000.
Q. Is the treating doctor required to prescribe generic drugs, as opposed to name brands? If the treating doctor is required to prescribe generics, can I as the adjuster deny a name brand drug on the basis of medical necessity?
A. According to Rule 134.502(a)(3), the doctor shall prescribe generic prescription drugs when available and clinically appropriate. If the prescribing doctor is prescribing a brand-name drug, he must specify on the prescription that the brand-named drug is being dispensed in accordance with applicable state and federal law and must maintain documentation justifying the use of the brand-name drug. Rule 134.503(e) allow the insurance carrier, injured employee, or pharmacist to request a letter of medical necessity from the prescribing doctor regarding the brand-name prescription. Regarding the denial of a name brand drug on the basis of medical necessity, this is not an adjuster function. Rather, all medical necessity issues are to be addressed on behalf of the carrier by its URA.
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