Several issues often pop up after a claimant is seen at the hospital following a work accident. Here are a couple of scenarios, resulting issues and possible solutions:
- Employer doesn’t know the claimant went to the hospital– Sometimes the Employer may be unaware the accident occurred. Other times, the Employer is aware of the incident and the claimant initially declines treatment and then goes on their own accord to the hospital. Either way, this doesn’t get reported to the carrier, and then follow up care is not authorized often times until it gets litigated. This gap in care and official work status does cause issues on the litigation side as we find ourselves fighting over missed time prior to the first authorized visit and clarity on work status.
One thing an Employer can do if the claimant declines medical care is to offer (at that moment) a facility if they should change their mind. And perhaps ask the following day to make sure they didn’t seek treatment on their own.
- Employer knows they went to the hospital but doesn’t report it to the carrier – This situation can cause several issues. First, if the Employer sends them to the hospital for a known work-related accident, that is the provision of a benefit and starts both the 14 day clock to deny the claim and the 120 day clock to pay and investigate. If more than 14 days goes by (but less than 120), the Employer/Carrier has to pay for all the benefits due up until a denial. After 120 days, we are stuck with the accident being compensable.
This would arguably not apply if the Employer sent them to the hospital for what they did not consider a WC injury, such as fainting or a cardiac episode.
- Claimant requests follow up care and none is provided– This could trigger the “Self-help provision” of the statute, 440.13(2)(c). Under this section, if the Employer/Carrier fails to provide care after it is requested, a claimant can go seek treatment on their own with whatever doctor they choose, and can request the Judge find the E/C responsible for the payment of the bills. If the Judge finds the treatment compensable, the opinions of the “self-help” claimant picked doctor becomes authorized, including the work status, and we could owe indemnity retroactive. However, the caselaw supports that if the JCC does find the treatment compensable, the E/C can pick the doctor moving forward, but is stuck with the past treatment and work status.
- No treatment after the hospital, and unclear work status– This happens when the hospital provides a limited work status, such as no work for three days then follow up with an orthopaedic. If it is several weeks before any care is authorized, we now have a gap in a clear work status. Where this often goes bad is once litigated, the claimant’s attorney either gets the authorized treater or an IME to state their work status in the initial visit would have been retroactive to the date of accident. We then are litigating a few weeks of benefits, which can be costly. It may make sense to address the indemnity prior to litigation if the gap is in fact the fault of the E/C. If the fault lies with the claimant we may be in a better position if the indemnity is denied.
As always, each case is fact specific. I am always available for questions and opinions.
Morgan Indek | Managing Partner