What to Do When Your Medical Treatment Is Denied Under Tennessee Workers' Compensation
We frequently get calls from injured workers telling us that their medical treatment has been denied by the Workers' Compensation Insurance Carrier. Discussed below are some of the reasons that treatment is denied and what injured workers should do when that happens.
One common reason that treatment is denied is because the Carrier claims that the worker has a preexisting condition. This alone is not a good basis for a denial. Under Tennessee law, injured workers are generally entitled to pick from a panel of three physicians. The chosen physician decides whether the injuries are caused by a workplace accident. Terry Lamm E. Miller Constr., Inc., et al., No. 2015-01-0429, 2016 WL 11577268, at *1 (Nov. 8, 2016) discussed below illustrates the importance of making sure that a panel doctor makes the determination.
In the Terry Lamm case, the Employee testified at an expedited hearing that he informed Employer's “safety guy” of his injury and was instructed to go to Lakeway Urgent Care. He was not given a panel of doctors as required under Tenn. Code Ann. Section 50-6-204. Dr. Sanabria at Lakeway provided the opinion that he could not relate the Employee's back injury to the Employee's work accident. Employee claimed that he injured his back lifting a steel beam. The Employee requested another physician to provide treatment. The Workers' Compensation Insurance Carrier denied that request. The trial court determined that because the Employee had described a work accident, he was entitled to a panel of physicians despite Dr. Sanabria's opinion.
This case illustrates that injured workers should be aware that they have a right to a panel of physicians. Insurance companies will try to trick workers by sending them to specific physicians. Injured workers should contact an attorney early in the process. There is a solution for the worker when they accidentally go to the Carrier's handpicked doctor. In that case, the worker can always file a Petition for Benefit Determination and demand that a panel is provided.
As a complete opposite scenario of the Terry Lamm case, treatment may be denied because the Authorized Treating Physician (i.e. a physician chosen off a panel) stated that the injury was not more than 50% caused by the work accident. Tenn. Code Ann. Section 50-6-102(14)(E) states that “the opinion of the treating physician, selected by the Employee from the Employer's designated panel of physicians, shall be presumed correct on the issue of causation but this presumption shall be rebuttable by a preponderance of the evidence.” In order to prove the workers' compensation doctor wrong in this scenario, the injured worker would need an alternative opinion from another doctor and to convince a judge that the alternative opinion is correct by a preponderance of the evidence.
Treatment is also often denied after it is put through Utilization Review. Utilization Review is a process by which the Carrier can challenge the appropriateness and necessity of medical treatment. When the injured worker's treatment is denied in Utilization Review, the worker must appeal the decision within 30 days of the denial.
If you are an injured worker and your claim is denied in Utilization Review, the best way to appeal that decision is to ask your Authorized Treating Physician to fill out form C35(A). After this form is delivered to the Medical Director for the Tennessee Department of Labor Workers' Compensation Division, the Medical Director will make a decision on the appeal. If you disagree with the decision of the Medical Director, you then have 7 days to file a Petition for Benefit Determination. The decision of the Medical Director becomes final after 7 days. The decision cannot be tested again for a period of 6 months.
If you have a Tennessee Workers' Compensation claim and your medical treatment has been denied, call the Law office of Brown and Roberto for a free consultation. We can be reached at (865) 691-2777.