GQ Corner

Q. I have a treating doctor who placed an injured worker at MMI with no permanent disability, but placed permanent work restrictions on the DWC-73. There are extent of injury disputes on file. I had requested a Designated Doctor exam to address MMI and IR prior to receiving the above certification and this is pending approval once the claimant contacts the DWC to confirm her address. My question is should I amend my DD request to have the DD also address extent of injury as well as return to work? Our extent of injury position is strong as both the treating doctor and our peer doctor agree on extent of injury.  

A. Whether to add extent to the examination is a matter of preference. There are positives and negatives associated with the addition of extent. You already have two favorable opinions on extent, and the likelihood that a doctor unfamiliar with the body parts in question could jeopardize the claim and subject the carrier to medical benefits during the pendency of a Post-DD RME and CCH. On the other hand, having the doctor address extent, MMI and IR at the same time permits the doctor to issue multiple certifications, which is a benefit. I personally do not like to add extent when we have a couple of favorable opinions on extent. I would, however, add the issue of return to work. 

Q. Under recoupment, if TIBS have been overpaid and taking credit from IIBs for the overpayment, is 25% still the percentage you can recoup up to from indemnity especially if there is no legal representation, DWC-24, etc.  If the adjuster has been taking more than 25% recoupment, do I owe IW any additional monies before IIBs are completed?  Based on his IR, we are NOT going to be able to recoup the full TIBs o/p, but it appears the handling adjuster was taking more than 25% from his IIBs.  Please advise.

A. Yes, you can recoup at 25%. However, I am leery of the fact that the prior adjuster was withholding a larger percentage without an agreement from the claimant. I would recommend that you calculate the amount that would have been recouped properly (25%), and compare it to the amount that was actually recouped at the higher percentage. Then, reimburse the claimant for any benefits that were withheld in excess. This is to mitigate any exposure for a violation that may or may not materialize in the future.