GQ Corner

Q: A recommendation has been made for the claimant to undergo surgery for the compensable injury. A required medical examiner previously opined that no further treatment would be medically necessary, but our utilization review agent pre-authorized the request for surgery. Is the carrier liable for the proposed operation?

A: Yes. The carrier is liable for all medical treatment that is related to and medically necessary for the compensable injury. The first component pertains to extent of injury, which is the province of the claims adjuster. The second pertains to medical necessity, which is the exclusive province of the utilization review agent. Given that there is no extent of injury dispute and the utilization review agent deemed the proposed surgery medically necessary, the carrier is liable for payment. You may and indeed should send medical evidence and opinions, such as those from peer reviewers and required medical examiners, to the utilization review agent for consideration in evaluating medical necessity, but its determination will ultimately control as regards the medical necessity question.

Q: The claimant parked his vehicle in an unauthorized area off the premises of the claim employer before the commencement of his shift. He fell while exiting his vehicle and sustained injuries. Do I have a reasonable basis the deny the claim?

A: Yes. While compensability questions of this nature are extremely fact-intensive and are decided on a case-by-case basis taking into account the unique facts and circumstances applicable to each scenario, you may dispute an injury arising out of and in the course and scope of employment in this case based on the information provided. Under the circumstances, the claimant may argue that the access doctrine, an exception to the general “coming and going” rule, places him within course and scope. However, that exception should not apply pursuant to the statute and prevailing case law since the claimant had not yet commenced work and indeed had not even arrived at the premises of the employer when the claimed injury occurred.