GQ Corner
Q: Claimant paid out of pocket for medical expenses allegedly related to a compensable injury. Her attorney is requesting reimbursement. Am I allowed to pay the facility directly for services rendered then require her to seek reimbursement from them, or am I required to reimburse her directly?
A: Pursuant to Rule 133.270, an employee can request reimbursement for health care for which the employee paid. The carrier has 45 days to take final action to approve or deny the request. Carrier is liable only for the reasonable and necessary treatments and for reimbursement up to the fee guideline MAR or contracted amount. Subsection(e) provides that payment goes to the injured worker, The employee can seek reimbursement for fees paid over the MAR from the health care provider.
Q: I have a question about initiating death benefits to a widow. We are approaching the 60th day. The widow has been contacted, and there are 3 dependent children with this widow. We have not received a marriage license or birth certificates. The death has been determined to be the result of a compensable injury.
Any recommendations on initiating benefits? The max DIBS rate is due. Should we issue total weekly amount to the widow and upon receipt of the birth certificates re-distribute to the children? Should we hold the children’s portion until information is received? Should we file dispute?
A: Since you have determined the claim is compensable, don’t worry about the 60 day deadline because that does not apply to the payment of death benefits.
Rule 132.17(f) provides that the earliest day you ever have to pay death benefits is the 15th day after the latest of: (1) receipt of the claim for death benefits; (2) final adjudication of a denial of compensability or liability; or (3) the expiration of carrier’s right to deny compensability/liability.
The widow has not submitted the documentation required by Rule 132.3. As such, you are not only not required to pay benefits, you should not because if it turns out that you paid benefits incorrectly, then you will have double liability. For example, this can occur when the widow never files the claim for death benefits. Under such scenario, the widow will be found to have waived her right to such benefits and you will be forced to pay the correct beneficiaries all of the money erroneously paid to the widow, potentially including the SIF.
The biggest problem that you run into is when there are multiple beneficiaries and you don’t receive all of the documentation in time to simultaneously initiate benefits. Minor beneficiaries are particularly difficult because they can file any time until they reach 19. However, there is no authority for holding a share of benefits and there is no authority for redistributing benefits already paid. The most that you can do is recoup any overpayment of benefits.
Thus, to minimize your potential overpayment, you should aggressively pursue the timely and simultaneous submission of all applications and ensure that they are properly reviewed and vetted. The first step in this process is to send all potential beneficiaries the PLN-12.
Q: I have an old law claim from 1980 where the employee had a right knee replacement in 2004. Claimant has never agreed to CSA so medical remains opened. In January 2015, Claimant asserted that stating his knee was again bothering him and he wanted to seek treatment. Claimant lives in Alabama, I advised him to seek treatment with a workers’ compensation doctor, but he never sought treatment.
Claimant called this week stating he needed to have back surgery and wanted to know if we would provide financial assistance. Claimant advised he has fallen numerous times due to his knee locking up and thought this could be why he needs to have back surgery. In his lengthy conversation he also advised he has ALS, but has not had any problems in years.
How should I proceed? Can I deny the treatment because he did not provide a specific event and/or because he has other conditions that may have caused his back problem?
A: Under old law, you would file a notice of controversion if you receive a medical bill that you intend to dispute, or if you are stopping benefits that are no longer related. In your case now, it does not appear that there is any indication that the lumbar is related. If he presents you with something implying that it is related, you would want to address it at that point, but until he does, you are not under any obligation to accept or agree to lumbar treatment. However, once you are presented with a bill or medical statement of causation, you would want to file notice of controversion.
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