Navigating the Game of Workers’ Compensation: Strategies for the Employer/Insurer to Implement in Accepted Claims against Claimant’s Not Complying with Medical Treatment
By: Jordan Brown
As in the hit series Game of Thrones and House of the Dragon, a workers’ compensation claim can be akin to a battle between powerful houses. One house represents House Employer/Insurer, while the other house represents House Claimant. Once a claim has been made, each house has an arsenal of tools at its disposal that can be utilized to push the trajectory of the claim in favor of either party. The battle between rival houses is governed by The Workers’ Compensation Act (the Act) and sets forth the guidelines a claimant and the employer/insurer must abide by to avoid failing out of compliance with the Act. With the goal of the Act to provide relief to individuals injured at work, each house’s responsibilities in sum creates a symbiotic relationship – one offers something in return for something else.
In the context of accepted claims where House Claimant is receiving weekly benefits, either temporary total disability (TTD) or temporary partial disability (TPD) benefits, House Employer/Insurer is given assurance, or an oath, that the claimant will avail themselves to reasonable medical treatment designed to effect a cure and provide relief from the workplace injury. This assurance is memorialized in O.C.G.A. § 34-9-200 and prohibits the claimant from refusing to submit to medical treatment provided by the employer/insurer. Given that the rules are codified and both houses are aware of its existence, one would assume the workers’ compensation claims flow easily from start to finish, right?
Unfortunately, that is not always the case. Situations arise where a claimant voluntarily refuses to continue medical treatment but continues to receive weekly benefits at the expense of the employer/insurer. When this occurs, what is House Employer/Insurer to do to restore balance caused by the claimant’s non-compliance? Two options are readily available that the employer/insurer can implement.
Filing of a WC-PMT(b)
Generally, a WC-PMT is a tool that is commonly employed by the claimant in pushing for medical treatment that has been recommended by the authorized treating physician. A WC-PMT form refers to a Petition for Medical Treatment where the filing party requests a conference call with the administrative law Judge and the opposing party to discuss the medical treatment at issue. The non-filing party, typically the employer/insurer, is required to show cause as to why the recommended treatment has not been authorized – absent completing the section notating that the treatment is being controverted for a particular reason. The playing field evened out with the codification of Board Rule 205(c) which allowed an employer/insurer to file their own version of a WC-PMT.
A WC-PMT(b) can be filed when approved medical treatment has been scheduled, the claimant received ample notice of the appointment and the claimant failed to appear for the authorized treatment. This strategy is typically implemented after consecutive failed appointments, so the administrative law judge can conclude the failure to attend scheduled appointments derives from more than a mere scheduling conflict. Once the WC-PMT(b) has been employed, the claimant has five business days before the scheduled conference call takes place. At the conference call, the claimant will have to provide adequate justification, or show cause, as to why they have failed to avail themselves to authorized medical treatment.
It is important to note the practical application of this avenue. Since the Act is creature of liberal construction, the claimant is generally awarded one more opportunity to avail themselves to treatment before the judge steps in and restores balance by suspending their income benefits. The claimant will be ordered by the judge to attend the next scheduled appointment or risk the suspension of their benefits. This strategy works well in cases where the claimant is pro se as it not overly litigious and has a quicker turn around than the second option at the employer/insurer’s disposal.
Filing a Motion to Suspend Income Benefits
The more litigious alternative to gain compliance from a claimant not appearing for medical treatment is to file a Motion to Suspend Benefits with the State Board. Typically reserved for cases where the claimant is represented by counsel, filing a motion can be an effective method of suspending benefits quickly. Once the Motion to Suspend has been filed, along with the supportive exhibits, the claimant will have 15 days to file a response for the judge’s consideration. Depending on the facts of the case and how prevalent the non-compliance is, after the 15-day response window expires, the judge can instantly order the suspension of the claimant’s benefits. However, if the claimant is pro se it is best to ensure the Motion was personally served on the claimant so an argument cannot be made that the claimant was unaware of the Motion being initially filed. Motions can be costly to prepare, but it does assert a strong stance that the employer/insurer will not sit back and continue paying income benefits while the claimant fails to uphold their part of bargain. While some cases may result in immediate suspension of benefits, some judges will give the claimant a final chance, similar to the WC-PMT(b) route, before issuing a subsequent order suspending benefits. Utilizing a litigation tool can be a gamble, but it is a strong tool to continue pushing the claim forward towards some form of resolution – either settlement or a hearing.
Both sides must relinquish something in order to obtain something in the workers’ compensation battle. These tools are effective resources to ensure the claimant continues through the workers’ compensation system to potentially return either to their current employer or a subsequent employer. Each case is different and calls for a unique approach and strategy.
Attorney Contact Info
Jordan Brown
jordan.brown@swiftcurrie.com
470.639.4855