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Utilization Review Explained

By: Douglas A. Williams

If you have been injured in a work injury, and are actively treating with a doctor, you may receive a “Utilization Review Request” in the mail. This document is often particularly confusing to those who aren’t in the legal profession. Many injured workers wonder whether the Utilization Review Request is an attempt to stop their weekly checks. Others fear the request may mean that they will be stuck paying medical bills.

When an insurance carrier files a Utilization Review Request, the carrier asks the Bureau of Workers’ Compensation to appoint an independent doctor to review the “reasonableness and necessity” of the injured worker’s treatment. So, for example, if the injured worker is seeing a chiropractor two times per week, the independent doctor would decide whether the worker needs to treat that frequently and whether the type of treatments provided by the chiropractor are reasonable and necessary. If the independent doctor finds the treatment reasonable and necessary, the insurance carrier must continue to pay for it. If the doctor determines that the treatment is unreasonable and unnecessary, the carrier is no longer responsible for paying for treatment with that doctor.

Injured workers should know that, regardless of how the Utilization Review Request is decided, his weekly checks will not be affected. Additionally, if the insurance carrier is excused from paying for treatment, the doctor is forbidden by law from billing the injured worker. Furthermore, the Utilization Review Request relates to the treatment provided only by the doctor who is the subject of the review. Finally, the doctor, the injured worker, or the insurance carrier has the right to appeal the Utilization Review doctor’s decision to a Workers’ Compensation Judge.

Who Decides if You’re Telling the Truth?

By: Sandra Weigel Kokal

The Pennsylvania Supreme Court will hear oral arguments in an upcoming case to decide whether the Commonwealth Court overstepped its appellate function in making credibility judgments which is the sole function of the workers’ compensation judge.

In workers’ compensation cases, the law has held the workers’ compensation judge (WCJ) is the sole fact finder. The WCJ has sole power to assess the credibility of witnesses and resolve any conflicts in the evidence presented in a workers’ compensation case. The WCJ as the ultimate fact finder has the authority and power to evaluate and weigh the evidence. The WCJ may accept or reject any evidence in whole or in part.

In the upcoming case to be heard by the Pennsylvania Supreme Court, the Court will decide if the Commonwealth Court erred in rejecting the WCJ’s findings. The WCJ in this case had found the testimony of an IRE physician insufficient to grant the Employer’s Modification Petition. The Commonwealth Court did not accept this finding.

Prior Pennsylvania Supreme Court case have upheld this power of the WCJ and have stated that Commonwealth Court has abused its discretion in usurping the function of the WCJ. Again, the WCJ is the ultimate fact finder and it is not the function of the appellate courts to ignore or reweigh the WCJ’s findings. The PA Supreme Court will again decide this issue.

Who Chooses my Doctor for a Work Injury?

If you have been injured at work it’s possible that your employer, or its workers’ compensation insurance carrier, have instructed you to treat with one particular doctor. Many injured workers believe that they must treat with the doctor to whom they are sent. However, this is not the case.

The Pennsylvania Workers’ Compensation Act permits an employer to maintain a list of panel of physician. Each list must contain at least six (6) different medical providers. It is true that, if your employer maintains such a list, the workers’ compensation insurance carrier only has to pay for treatment provided by those doctors – at least during the first 90 days after the first date of treatment for the injury. But, what employers and insurance carriers rarely tell injured workers is that the worker has the right to choose the doctor (or doctors) who will provide treatment. So, if your employer tries to tell you that you must see one particular doctor, ask your employer to see the list of panel physicians – and then choose whichever doctor with whom you want to treat.

It’s also important to remember that you have the right to switch from one doctor to another if you desire. Thus, if you’ve chosen to treat with one doctor on the list of panel physicians and you are not pleased with that doctor, you have the right to begin treating with a different doctor. In fact, you can treat with all of the doctors on the list of panel physicians if you wish. As long as you are treating with one of the doctors on that list, the insurance carrier must pay for the treatment.

Finally, you should also be aware that, if you’re employer doesn’t maintain a list of panel doctors, you are free to treat with any doctor of your choosing. Moreover, if you wish to see a specialist – such as an orthopedic surgeon, neurologist, etc. – you are not required to get a referral from your family doctor as is often the case with health insurance plans. Rather, you may simply call the doctor, make the appointment, and the insurance carrier will have to pay for the treatment as long as the treatment was necessitated by the work-related injury and is reasonable and necessary.

UPDATE ON THE VA CAMP LEJUNE CLAIMS

By: Susan Paczak

The VA will now granted disability compensation benefits to veterans who served at Camp Lejune for any length of time between August 1, 1953 and December 31, 1987 if they have developed certain diseases. The diseases the VA now recognizes are:

  • Kidney cancer
  • Liver cancer
  • Non-Hodgkin lymphoma
  • Leukemia
  • Scleroderma
  • Multiple myeloma
  • Parkinsons disease
  • Aplastic anemia/Myleodysplastic syndromes

This means that if a Veteran who served at Camp Lejune between 1953 and 1987 develops one of these diseases and applies for benefits the VA will automatically recognize the disease as service-connected and grant disability compensation benefits. The VA will pay benefits not only for those on active duty, but also for veterans who were assigned to Camp Lejune while in the Reserves or National Guard.

Although the VA has not put out the necessary regulations to cover these diseases, a veteran who served at Camp Lejune during the time of the water contamination should apply for benefits immediately. The VA will hold the claim and grant benefits as soon as the regulations are finished. As the date benefits become payable depends on the date the veteran applied for benefits, the veteran should apply immediately. If a Camp Lejune veteran died from one of the listed diseases, his widow/er should file a claim for benefits immediately.

The VA may add other diseases to the list after more research is done. If the veteran has a disease s/he thinks was caused by the water at Camp Lejune, the veteran should file a claim immediately. Even if the claim is denied, if the disease is added to the list later on, the VA will most likely grant benefits back to the date of the original application. Also, the veteran can still prove that a disease not on the list is related to the chemicals in the water, if there is medical evidence from a doctor to support the claim.

The So-Called Independent Medical Examination

By: Thomas C. Baumann

If you are injured on the job the workers compensation insurance carrier has the right under the Pennsylvania Worker’s Compensation act to require you to submit to a so-called independent medical examination(IME). While the examination is referred to as” independent”, it is rarely truly independent. There are numerous physicians in Western Pennsylvania to make several hundred thousand dollars a year examining injured workers at the request of employers and insurance companies and testifying on behalf of those entities. The lucrative nature of such business often renders the examination rather one-sided.

Injured workers can do several things to protect themselves with attending an IME. The injured worker should always time exactly how long he or she spends with the IME doctor. Based on feedback that Abes Baumann receives from its clients, the examinations rarely exceed 5 to 10 minutes. Yet, the IME doctors often testified they spend a half-hour to an hour with the worker. By timing the examination, the injured worker can testify how brief the examination was and help undermine the credibility of the IME doctor.

The injured worker should write down the time he or she arrived at the facility for the examination. He or she should then record the exact time he/she returned to the vehicle. Recording this timeframe will correlate with the actual time spent with the physician and lend credibility to testimony as to the brevity of the examination.

Injured workers should make notes regarding what happened at the examination immediately following the appointment. By writing down what happened, injured workers can buttress testimony regarding how short a period of time was spent with the doctor.

If the injured worker has a healthcare provider in the family or one who is a close friend, that person can be brought to the examination. The Worker’s Compensation act provides that an injured worker has the right to have a healthcare provider of his or her choosing attend the examination. Healthcare providers can include nurses, chiropractors or physicians. When a healthcare provider attends an IME, there is usually a much more thorough and fair evaluation.

Injured workers should always see treating physicians as soon after the IME as possible. This allows for fresh evidence to rebut the  opinions of the IME doctor. When you receive notice of an IME, and injured worker should always speak to his/her lawyer. If the injured worker has not yet retained counsel, he/she should definitely talk to a lawyer once they receive notice of an IME. That almost always means the insurance carrier starting to move against the worker.

THE DOWN-SIDE OF AN EMPLOYER PROVIDED VEHICLE

By: Roger D. Horgan

You have just landed a new job, or received a promotion, which has the added benefit of a company car. You even get to take it home and use it as your personal car. What could possibly be wrong with that set up?

A lot. You get in an accident while driving your shiny new company car. The other driver admits responsibility, and his insurance company tenders his policy limits, which, in Pennsylvania, may be as little as $15,000.00. Since the responsible driver has inadequate insurance, you want to look at the company car policy to see if it has any underinsured motorist coverage, known as UIM coverage. The policy covering the employer-provided vehicle may or may not have UIM coverage. Further, even if it has such coverage it still may be inadequate to cover the value of a serious injury claim. The next place to look is the policy you have purchased to cover your personal vehicles. You determine, thank goodness, that you have purchased a great deal of UIM coverage, and initially feel relief that you had such great foresight to protect you and your family.

Unfortunately, your relief is likely to be short lived because your insurance carrier is likely to deny your UIM claim. Virtually every automobile insurance policy issued in the state of Pennsylvania contains a limitation on UIM claims that applies when the insured is injured while occupying a vehicle that he does not own, but regularly uses. This is known as the Regularly Used/Non-owned Vehicle Exclusion. These exclusions are written into auto insurance policies because the insurance company does not want to be responsible for vehicles that it does not insure, and for activities of the driver beyond what the insurance company expects when the policy is issued. They contend that, if required to pay to such UIM claims, they would be forced to pay benefits for claims that were not anticipated by the premiums they charged.

The saddest examples of the Regularly Used/Non-owned Vehicle Exclusion have to do with police officers who are seriously injured in an automobile accidents while on the job. While the officer was entitled to the police equivalent of worker’s compensation, those benefits are not intended to and do not cover all of his damages. His only sources of compensation for his other damages is a claim against the defendant driver, plus any available UIM coverage. Most employers do not provide UIM coverage on their vehicles because it is not required by law, and therefore it is an avoidable expense. Even if the employer does have UIM coverage it may well be inadequate in serious injury cases. By operation of the Regularly Used/Non–owned Vehicle Exclusion in his personal policy the injured police officer cannot tap into the UIM coverage he purchased, and he can be left far from fully compensated for his losses.

This outcome was challenged by a police officer in the Pennsylvania Supreme Court case of Williams v. GEICO Gov’t Employees. Ins. Co., 613 Pa. 113 (Pa. 2011). The policy language prohibited recovery of UIM benefits, but the officer argued that enforcing that language, and denying such benefits, violated the strong public policy in favor of protecting police officers. The court sympathized with the officer’s predicament, but nevertheless found that public policy was not violated by the Regularly Used/Non-owned Vehicle Exclusion, and confirmed the denial of his claim for UIM benefits.

“In summary, we reaffirm the decision in Burstein, holding that the regular-use exclusion is not void as against public policy. A contrary decision is untenable, as it would require insurers to compensate for risks they have not agreed to insure, and for which premiums have not been collected.” Williams v. GEICO Gov’t Employees. Ins. Co., 613 Pa. at 135 (Pa. 2011).

This is now well-settled law in Pennsylvania, and the question is what can a person who regularly drives a vehicle which he does not own to protect himself? Unfortunately, there appears to be no perfect answer. One suggestion is to purchase accident disability coverage separate and apart from automobile insurance. However, recovery under such policies is generally limited to a particular, monthly dollar amount. Worse, some of them would reduce payments of benefits by the amount of workers compensation or similar benefits received by the victim. Another suggestion would be to convince the employer, if possible, to purchase adequate UIM coverage for the vehicles it provides to employees. This should be a part of any labor/management negotiations where employees are provided with vehicles by the employer, and it should be requested by any employee who regularly drives a vehicle provided by an employer. In any event, be careful out there!

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