Morgan’s Tip of the Week – PFB Responses
Greetings, well we are almost 11 months into the post-Castellanos world, and one thing is for certain; there has been an increase in Petitions for Benefits.
Compiling the good and the bad of what I have seen over the past few months, here are a few do’s and dont’s in responding to PFB’s.
DONT’S
- Don’t be vague in your response if you can be specific. If your response is unclear that you are agreeing to provide the benefit, you will owe a fee. A “maybe” type answer is a denial. (for example- will pay the medical bills when received on proper form IF related).
- Don’t use the words “not in the course and scope of employment” if you can avoid it. This allows the claimant to pursue a liability claim as WC does not apply if they are not in the course and scope. You can simply say “no compensable accident”.
- Don’t forget to confirm the AWW you are using is correct. Confirm with the employer about the status of any fringe benefits/Health Insurance. You must include the ER’s cost of fringe benefits in the AWW when the benefits end, regardless of why the benefits ended. The AWW is pretty much pled on every PFB.
DO’S
- Do use your time wisely. Yes the statute says you shall respond within 14 days, and many carriers are requiring the adjusters to do so. However, fees do not attach as long as you respond within 30 days. If you don’t know whether you owe the benefit yet, talk to your supervisor about whether you can wait to respond. If you deny within 14, and you file an amended response or provide the benefit later you will owe a fee in most cases.
- Do follow up on medical bills. If you say you will pay the bill when received on proper form, but don’t request it or take any action, you may still owe a fee down the line because you did not actually provide the benefit. Send a letter/request and diary a follow up.
- Do request post-accident earnings to make sure you don’t owe any TPD. Don’t rely on the employer telling you they are being accommodated.
- Do abuse your defense attorney. Get us involved in wording and responses.
As always, feel free to abuse me.
Sincerely,