Why resist a good employee’s treatment requests?

A good employee was rear-ended while driving a company truck.  The BWC denied the claim, so the employer appealed and went to hearing to get the claim allowed.  The employee did not miss any time from work, and continued to work full duty.  After some physical therapy, the employee selected a chiropractor to be his medical provider.  The chiropractor requested multiple consultations plus a TENS trial.  The MCO and Ohio BWC denied all requests as being related to disallowed conditions.  The employee’s attorney appealed the denials.  Why should the employer pay for an attorney to attend the appeal hearings when it fought to get the claim allowed?

Additional consultations can lead to multiple diagnostic tests like MRI, CT scans and x-rays, and/or active physical therapy and/or medications, which means increased medical costs.

The employee’s attorney will file for permanent partial disability (PPD) compensation.  PPD is the “reward money” for being injured and the attorney usually takes 1/3 of the compensation as his fee.  At hearing, the attorney will announce the amount of medical expenses as an argument for a larger PPD percentage.

Once compensation is paid, the BWC will calculate and add reserves into the claim costs.

As long as the claim is active, (i.e., the employee gets treatment or follow up visits or medications or more compensation), the reserves will be included in the claim costs that impact the employer’s premium rates.  The claim has to be inactive for at least 6 months before the September 30 survey date to get the reserves suppressed.  Medical costs and compensation continue to impact the premium rates for five years after the year of injury.

So an employer may choose to resist a good employee’s treatment requests when the treatment will be for unallowed conditions and/or when the employee has an attorney.  If the claim will be inactive more than 6 months before the survey date, then the employer needs to decide which will be worse for future premium rates, the increased medical expenses or the reserves that will not be suppressed while the treatment requests are actively contested.  A good TPA should be able to guide this decision with future premium rate predictions.

Plus, when an employer is not represented at a hearing, hearing officers tend to grant whatever the employee’s attorney requests.  Only an attorney is permitted to discuss the medical records so it’s important that the employer have legal representation at Industrial Commission hearings.


Posted in claims, premiums, TPA.