GQ Corner
Q. The claimant was driving a company vehicle when he hit a patch of ice, causing him to spin and hit a barricade. The claimant was positive for marijuana. Please provide an opinion on compensability of the claim based upon the fact that he was positive for illegal substance.
A. You do have a basis on which to dispute the claim in light of this post-accident positive drug screen. I recommend you specifically raise both issues of compensability and relief from liability under Section 406.032 due to the fact that any alleged injuries occurred while the claimant was in a state of intoxication. The positive screen results in a rebuttable presumption that the claimant was intoxicated at the time of the motor vehicle accident and injuries.
Q. Claimant was on the clock, went to the bathroom at work, and fell down in the bathroom hurting her knee. MRI completed 1/22/21 showed an ACL tear 5mm cartilage defect of the lateral condyle with adjacent small area of bone marrow edema. The treating provider is requesting Assisted Left knee ACL reconstruction with allograft Achilles tendon, and possible osteochondral autograft transfer from a focal full-thickness lesion on the lateral femoral condyle. What should I do?
A. The claim is compensable because the Personal Comfort and Convenience Doctrine covers the course and scope element; and because the fall was on the instrument of the employer, the “arise out of” element was met. You should try to determine the extent of the compensable injury. The treating doctor’s request for surgery is a request for preauthorization. The carrier’s URA would determine if the requested procedure is medically necessary. If the URA determines that the procedure is medically necessary, then the carrier has conceded that issue. If the surgery is for the compensable injury, then the carrier is liable for the cost of the surgery based on the Medical Fee Guidelines.
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