Often employers are confronted with situations in which an employee’s claim is either fraudulent or at least exaggerated regarding its severity
Cookeville – The Workers’ Compensation system in Tennessee is often frustrating and difficult to navigate for Tennessee employers.
Often employers are confronted with situations in which an employee’s claim is either fraudulent or at least exaggerated regarding its severity. In general, the Tennessee Workers’ Compensation system and the Court tend to favor employees regarding compensability determinations. The 2014 legislative changes did mitigate this somewhat.
Before 2014, Courts gave deference to the employees in close questions of law or fact. The establishment of the new Bureaus of Workers’ Compensation Claims and the Court of Workers’ Compensation Claims in 2014 changed that. But, the fact remains that employers are usually fighting an uphill battle when contesting medical causation and issues of whether an injury occurred in the course and scope of employment.
The denial of a claim can have significant repercussions. An employer or insurance carrier can utilize Form C23 to deny a claim. This effectively stops both medical and indemnity benefits. However, if determined that a claim was denied wrongfully, the consequences can be severe. These consequences can include penalties from the Bureau of Workers’ Compensation Claims and the requirement that an attorney for the employee be reimbursed.
If a claim is denied early, normally the medical treatment will be in the hands of the employee instead of the employer, and the state of Tennessee has the right to provide a panel of physicians from which an employee can choose to treat.
An early denial of a case may result in the employee having the freedom to choose their physicians and the employer will essentially lose the right to control the medical treatment.
That is important because an authorized treating physician selected from a panel is presumed correct on several legal issues.
This presumption applies to medical causation and impairment.
As such, it’s imperative that if an employer and/or insurance carrier chooses to deny a claim that they assess whether a full and sufficient investigation of the facts and circumstances of the claim has been conducted. Furthermore, the Courts frown upon an employer or insurance carrier deciding to deny a case based on medical causation when medical proof is absent. The Court would prefer an employer or insurance carrier when in doubt of the compensability of a claim for medical causation reasons, to provide a panel of physicians and then posit a series of causation questions to the authorized treating physician.
Then the employer can make a denial determination based on that physician’s conclusions and determinations regarding medical causation. Employers and insurance carriers are on a firmer footing if, instead of a medical causation determination, the decision is on an affirmative defense.
Affirmative defenses in Tennessee include things like notice, the statute of limitations, willful misconduct, etc.
Again, the court will scrutinize the facts and circumstances upon which the affirmative defense is based, and there could be consequences in the way of penalties and reimbursement of attorney’s fees if a claim is wrongfully denied.
It is recommended that if an employer is seeking to deny a claim that they consult with a legal expert. Another frustration common to workers’ compensation cases is the changing landscape of medical causation testimony. Oftentimes doctors will respond to causation letters, but later in deposition testimony will change or alter the nature of their medical opinions. Also, additional independent physicians can be retained whose opinions can change the landscape of a case.
The Courts are placed in an unenviable position of having to choose between which medical professional is more credible or believable. Judges are not medically trained and so it’s quite a challenge for the court system to navigate these waters.
Statistically 99% of Workers’ Compensation cases in Tennessee, legitimate or otherwise, settle. A valuable tool to resolve cases that are either fraudulent or questionable in nature and extent of disability can be resolved on what is called a “doubtful and disputed bases.” This is a resolution in which the parties simply agree to pay money and refuse to acknowledge whether the claim is compensable.
This allows for a dispute resolution and the closure of all future medical treatment without the necessity of going through a long, protracted and expensive process of litigation.
An employer’s relationship with their insurance carrier can be of great value. Typically, employers will either be fully insured and employ an insurance company to function as a third-party administrator or they will rely entirely on an insurance carrier to not only handle a claim but also provide medical and indemnity benefits. Typically, a successful denial of a claim will depend upon the information that is provided to the insurance carrier or TPA from the employer. As such, cooperation and communication between an employer and an insurance carrier can be invaluable in making a denial stick.
In conclusion, employers are encouraged to work closely and report regularly to their insurance carrier and defense counsel to properly navigate the waters of a C23 Notice of Denial. Given the potential consequences, it is important to weigh all the pros and cons before denying a claim.
Sometimes emotions can be high regarding an employee’s behavior and the decision to deny a case should be based not on emotions but on logic, facts and applicable laws and regulations.
Image by rawpixel.com on Freepik.
